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PRACTICAL TREATISE 



ON 



DISEASE IN CHILDEEN" 



EUSTACE SMITH, M.D., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS ; PHYSICIAN TO HIS MAJESTY THE KING OF THE 

BELGIANS ; PHYSICIAN TO THE EAST LONDON CHILDRENS' HOSPITAL, AND TO THE 

VICTORIA PAKE HOSPITAL FOR DISEASES OF THE CHEST 






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NEW YORK 
WILLIAM WOOD & COMPANY 

56 & 58 Lafayette Place 
1884 






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COPYRIGHT, 18S4, 

B* WILLIAM WOOD & COMPANY 



TROWS 

PRINTING AND BOOKBINDING COMPANY, 

NEW YORK. 



INSCRIBED TO 



Sir ftnivzxo Clark, Bart., HI. SB., 



IN TOKEN OF SINCERE FRIENDSHIP 



BY THE AUTHOR. 



PREFACE 



It was not without hesitation that the author consented to the pro- 
posal made to him by Messrs. Wood & Company, of New York, that 
he should write for them a complete Treatise on the Diseases of In- 
fancy and Childhood. The length of time which would be required 
for the completion of a task so considerable, and, especially, the knowl- 
edge that many manuals of varying merit were already in the field, in- 
disposed him to attempt a work which must necessarily prove not only 
long but laborious. Encouraged, however, by the reflection that his op- 
portunities for studying these complaints had been abundant ; that in the 
course of more than twenty years he had acquired a mass of valuable 
material, and that of existing books few dealt with more than a part 
of the subject, he thought himself justified in believing that a treatise 
which undertook to discuss the whole subject of disease in early life, 
and to deal with the matter purely from a clinical stand-point, might 
not be without its uses. 

The constitutional peculiarities of childhood, and the weakness due 
to immaturity, so shape the course and symptoms of disease that there 
are few complaints which do not assume special features when present 
in the young. Consequently the author has not hesitated to admit 
into his pages descriptions of every form of illness which is capable of 
being influenced in its manifestations by the early age of the patient. 
Those only have been purposely omitted which, like diabetes, present 
exactly the same characters in the child that they do in the adult. 

Each subject has been treated as fully as the space would allow, 
but many faults of omission may, no doubt, be discovered. The 
author, however, has striven to satisfy all clinical requirements, and 
where much must be left out, that the book may be kept within rea- 
sonable limits, has been anxious to omit nothing of real value to the 
practitioner. 

In the composition of the work the use of statistics has been gener- 
ally avoided, for unless dealing with enormous numbers little that is 



VI PEEFACE. 

trustworthy can be obtained from this method of inquiry. In fact, 
there can be little doubt that very erroneous impressions have been 
sometimes derived from statistical calculation based upon an insufficient 
number of cases. 

In order to increase the usefulness of the book, much care has been 
bestowed upon the sections relating to diagnosis and treatment. 'No 
attempt, however, has been made to include in the directions for treat- 
ment an enumeration of all the remedies which have been suggested 
for the cure of the several forms of illness. Such excess of detail not 
only fills the page with information often of doubtful value, but tends 
rather to confuse the reader than to instruct him. Moreover, it gives 
to this branch of therapeutics an importance which, in the case of chil- 
dren, it does not always possess. In the case of a young patient, judg- 
ment in feeding and care in sanitary arrangements not seldom consti- 
tute the sole necessary treatment of the illness. Quiet, rest, appropriate 
food, and plenty of fresh air will often restore the health without the 
aid of physic ; or if physic seem called for, the remedies needed are 
simple and few. But whatever be the nature of the malady, and how- 
ever elaborate may be the medication required, the details of nursing 
should always take precedence of those of drug-giving. Keeping this 
truth in view, the author has been careful to give due prominence to 
the subjects of diet and hygiene ; and in the matter of drugs has con- 
fined himself, for the most part, to recommending those only which 
experience has taught him to value, and upon which, therefore, he has 
himself been accustomed to rely. 

For purposes of illustration a number of concisely narrated cases 
have been introduced into the text. Most of these have been selected 
from the author's case-books, but a few are taken from the practice of 
his hospital colleagues. To these colleagues, for their kindness in 
placing their cases at his disposal, the author desires to express his 
deep obligations. 

George Street, Hanover Square, 
June, 1884. 



TABLE OF CONTENTS. 



PAGE 

Introductoky Chapter 1 

Physiological peculiarities of early life, 1 ; causes of sudden death, 5 ; conva- 
lescence, 5 ; definition of infancy and early childhood, 5 ; clinical examin- 
ation of infants, 6 ; inspection of the face, 6 ; attitude, 8 ; cry, 8 ; ab- 
sence of cry, 9 ; the pulse, 9 ; the respirations, 10 ; the temperature, 10 ; 
pyrexia from rapid growth, 11 ; movements of the chest and belly in 
breathing, 12 ; inspection of the mouth and throat, 13 ; treatment, 14 ; 
forced feeding, 14 ; reducing temperature, 15 ; baths, 16 ; internal rem- 
edies, 18 ; abuse of aperients, 19. 



13 art 1. 
THE ACUTE INFECTIOUS DISEASES. 

CHAPTER I. 
Measles 21 

The contagious principle, 21 ; morbid anatomy, 22 ; symptoms, 22 ; pre-erup- 
tive period, 22 ; the rash, 23 ; catarrh, 23 ; asthenic measles, 24 ; re- 
lapses, 24 ; complications, 25 ; sequelae, 26 ; diagnosis, 26 ; prognosis, 27 ; 
treatment, 28. 

CHAPTER II. 
Epidemic Roseola „ „ . . . . . . „ .„, B 30 

Symptoms, 30 ; diagnosis, 31 ; treatment, 31. 

CHAPTER HL 
Scarlet Fever , 32 

Causation, 32 ; morbid anatomy, 33 ; symptoms, 33 ; invasion, 34 ; eruptive 
stage, 34 ; the rash, 34 ; temperature, 35 ; the desquamative stage, 36 ; 
malignant scarlet fever, 36 ; complications and sequelae, 37 ; scarlatinous 
rheumatism, 38 ; albuminuria and uraemic symptoms, 39 ; latent scarlet 
fever, 40 ; diagnosis, 41 ; prognosis, 42 ; illustrative case, 42 ; treatment, 

CHAPTER IV. 
Chicken-pox 48 

Symptoms, 48 ; temperature, 48 ; gangrenous varicella, 49 ', treatment, 50. 



viii CONTENTS. 

CHAPTER V. 

PAGE 

Cow-pox — Vaccination 51 

Symptoms and course, 51 ; protective value of vaccination, 52 ; method of 
vaccinating, 53 ; occasional sequelae, 54. 

CHAPTER VI. 
Small-pox 55 

Morbid anatomy, 55 ; symptoms, 56 ; incubation, 56 ; invasion, 56 ; compli- 
cations, 59 ; varieties, 60 ; diagnosis, 61 ; prognosis, 62 ; treatment, 62. 

CHAPTER VII. 
Mumps 65 

Morbid anatomy, 65 ; symptoms, 65 ; incubation, 65 ; temperature, 65 ; me- 
tastasis, 66 ; deafness, 66 ; diagnosis, 67 ; treatment, 67. 

CHAPTER VHI. 
Cerebro-spinal Fever 68 



Causation, 68 ; morbid anatomy, 68 ; symptoms, 69 ; rash, 69 ; nervous symp- 
toms, 69 ; temperature, 70 ; paralysis, 70 ; convulsions, 70 ; varieties, 
71 ; form in infancy, 71 ; diagnosis, 72 ; prognosis, 73 ; treatment, 73. 



CHAPTER IX. 
Enteric Fever 



Causation, 74 ; morbid anatomy, 75 ; symptoms, 76 ; first week, 76 ; second 
week, 77 ; third week, 77 ; digestive organs, 78 ; the urine, 78 ; special 
senses, 79 ; temperature, 79 ; duration, 80 ; case, 80 ; mode of death, 81 ; 
relapses, 82 ; secondary pyrexia, 82 ; convalescence, 82 ; diagnosis, 83 ; 
prognosis, 84 ; treatment, 85. 



■ 



CHAPTER X. 
Diphtheria 



Diphtheria and croup, 88 ; causation, 90 ; morbid anatomy, 91 ; symptoms, 
93 ; mild form, 93 ; severe form, 94 ; albuminuria, 95 ; laryngeal diph- 
theria, 95 ; dyspnoea, 96 ; malignant form, 97 ; case, 97 ; secondary diph- 
theria, 97 ; complications, 97 ; nasal diphtheria, 98 ; cutaneous diphtheria, 
98 ; inflammatory complications, 98 ; thrombosis of heart, 98 ; cardiac 
dyspnoea, 98 ; apncea from laryngeal obstruction, 99 ; sudden death, 99 ; 
paralysis, 99 ; diagnosis, 100 ; prognosis, 102 ; treatment, general, 103 ; 
local, 104 ; tracheotomy, 105. 

CHAPTER XI. 

ERYSIPELA8 109 

Causation, 109 ; morbid anatomy, 110 ; symptoms, 111 ; rash, 111 ; fever, 
111 ; complications, 111 ; diagnosis, 112 ; prognosis, 112 ; treatment, 113. 

CHAPTER XII. 

Whooping-cough , f , . . . 114 

Causation, 114 ; duration of infection, 114 ; pathology, 114 ; nature of the 
disease, 115 ; symptoms, 115 ; the cough, 116 ; the whoop, 116 ; haemor- 
rhages, 116; complications, 117; ulceration of tongue, 117; bleeding 
from ears, etc., 118; digestive troubles, 118; nervous accidents, 118; 
pulmonary lesions, 119 ; sequelae, 120 ; diagnosis, 122 ; prognosis, 123 ; 
treatment, 124; of complications, 127. 



CONTENTS. IX 



Jkrt 2. 
GEJSTEEAL DISEASES NOT INFECTIOUS. 

CHAPTER I. p AGE 

Rickets . 129 

Causation, 129; bad feeding, 129 ; bad air, 130; relation to syphilis, 131 ; re- 
lation to tuberculosis, 131 ; nature, 131 ; morbid anatomy, 132 ; ossifica- 
tion of bone, 132 ; softening of bones, 133 ; changes in internal organs, 
133 ; the urine, 134; effects of bone changes, 134 ; on the contents of the 
chest cavity, 134; relation to osteo-malacia, 135; "congenital rickets," 
135 ; symptoms, 136 ; distortion of bones, 137 ; chest, 139 ; spine, 139 ; 
long bones, 140 ; general nutrition, 140 ; complications, 142 ; diagnosis, 
143 ; prognosis, 143 ; treatment, 144. 

CHAPTER II. 
Ague 147 

Causation, 147 ; morbid anatomy, 147 ; symptoms, 148 ; the cold stage, 14S ; 
the hot stage, 148 ; the sweating stage, 148 ; stages often ill developed, 
148 ; temperature, 149 ; urine, 149 ; malignant form, 149 ; anaemia, 149 ; 
hematuria, 149 ; diagnosis, 149 ; prognosis, 150 ; treatment, 151 ; hypo- 
dermic injection of quinine, 151. 

CHAPTER III. 

Acute Rheumatism 153 

Frequency in children, 153 ; causation, 153 ; morbid anatomy, 154 ; symp- 
toms, 154 ; inflammation of joints, 155 ; pericarditis, 155 ; fewness of its 
symptoms, 155 ; illustrative case, 155 ; occasional severity of symptoms, 
155 ; pericardial friction, 156 ; effusion, 156 ; elevation of heart's apex, 

157 ; illustrative case, 157 ; suppurative pericarditis, 157 ; endocarditis, 

158 ; ulcerative endocarditis, 158 ; pleurisy, 158 ; illustrative case, 158 ; 
pneumonia, 159 ; hyper-pyrexia, 159 ; rheumatism of abdominal wall, 

159 ; fibroid nodules, 160 ; duration, 160 ; relapses, 160 ; chronic rheu- 
matic pains, 161 ; diagnosis, 161 ; of pericarditis, 161 ; endocarditis, 162 ; 
ulcerative endocarditis, 162 ; prognosis, 162 ; occasional disappearance of 
cardiac murmurs, 163 ; treatment, 163 ; salicylate of soda, 164 ; impor- 
tance of rest, 165. 

CHAPTER IV. 

Spontaneous Gangrene 166 

Pathology, 166 ; morbid anatomy, 167 ; symptoms, 167 ; disseminated form, 
168 ; illustrative cases, 168 ; gangrene of extremities, 169 ; dry and moist 
varieties, 169 ; of vulva, 170 ; diagnosis, 170 ; prognosis, 171 ; treatment, 
171. 



JJort 3. 
THE DIATHETIC DISEASES. 

CHAPTER I. 
Scrofula 173 

Causation, 173 ; hereditary tendency, 173 ; exciting causes, 174 ; morbid an- 
atomy, 174 ; caseation of glands, 175 ; symptoms, 175 ; variety of the 
lesions, 176 ; cutaneous abscesses, 177 ; disease of bones and joints, 178 ; 
of the spine, 178 ; caseation of glands, 179 ; of cervical glands, 179 ; of 
bronchial glands, 180; its consequences, 181 ; asthmatic attacks, 182; 
alteration in physical signs, 182 ; of mesenteric glands, 183 ; its conse- 
quences, 184 ; diagnosis, 185 ; prognosis, 186 ; treatment, 187. 



X * CONTENTS. 

CHAPTER II. page 

Acute Tuberculosis 190 

Three forms, 190 ; causation, 190 ; hereditary tendency, 190 ; acute specific 
diseases, 191 ; the tubercle bacillus, 191 ; morbid anatomy, 191 ; the gray 
granulation, 192 ; the giant cell, 192 ; lung changes, 193 ; lesions of in- 
testines, 193 ; of the spleen, 193 ; of the bladder, 193 ; nature of cheesy 
matter, 194 ; symptoms, 194 ; gradual onset, 194 ; temperature, 195 ; 
oedema of legs, 195 ; local symptoms, 195 ; in brain, 195 ; in lung, 196 ; 
illustrative case, 196 ; in bladder, 197 ; in other organs, 197 ; duration, 
198 ; diagnosis, 198 ; from gastric catarrh, 198 ; from infantile atrophy, 
199 ; of pulmonary complication, 199 ; of tubercle of bladder, 199 ; prog- 
nosis, 200 ; treatment, 200. 

CHAPTER III. 

Infantile Syphilis 202 

Causation, 202; influence of the father and mother, 202; Colles's law, 202 ; 
acquired syphilis, 203 ; morbid anatomy, 203 ; affection of mucous mem- 
branes, 204 ; of solid organs, 204 ; of bones, 206 ; two varieties, 206 ; 
Parrot's views, 206 ; dactylitis, 207 ; affection of bones of skull, 207 ; 
cranio-tabes, 208 ; symptoms, 208 ; snuffling, 209 ; rash, 209 ; complexion, 
209 ; affection of hair and nails, 210 ; the cry, 210 ; thickening of the 
bones, 210 ; pseudo-paralysis, 210 ; true paralysis, 210 ; general nutrition, 
210; relapses, 211 ; sequelae, 211; diagnosis, 211 ; prognosis, 213 ; treat- 
ment, 213. 



flart 4. 
DISEASES OF THE DUCTLESS GLANDS AND BLOOD. 

CHAPTER I. ' 

Leucocythemia .' 216 

Causation, 216 ; morbid anatomy, 216 ; symptoms, 217 ; enlargement of 
spleen, 217; anaemia, 217; temperature, 218; hemorrhages, 218; en- 
largement of glands, 218 ; diagnosis, 218 ; from enteric fever, 218 ; from 
lymphadenoma, 219 ; prognosis, 219 ; treatment, 219. 

CHAPTER II. 

Lymphadenoma 220 

Causation, 220 ; morbid anatomy, 220 ; changes in lymphatic glands, 221 ; in 
spleen, 221 ; in liver, 222 ; kidneys, 222 ; adenoid new growtbs, 222 ; 
blood, 222 ; symptoms, 222 ; regular, 223 ; illustrative case, 223 ; glandu- 
lar swellings, 224 ; temperature, 224 ; cachectic stage, 224 ; anaemia, 
224 ; early local symptoms, 225 ; illustrative case, 225 ; accidental symp- 
toms, 226 ; pressure signs, 226 ; paralysis, 226 ; illustrative case, 226 ; 
diagnosis, 227 ; prognosis, 227 ; treatment, 227. 

CHAPTER III. 

Anaemia 229 

Frequency of impoverishment of the blood in children, 229 ; reasons for this, 
229 ; use of the blood in nutrition, 230 ; causation, 230 ; two classes, 230 ; 
morbid anatomy, 231 ; idiopathic anaemia, 232 ; symptoms, 232 ; com- 
plexion, 232 ; breatlilessness, 232 ; anaemic murmurs, 233 ; epistaxis, 233 ; 
headache, 233 ; symptoms of idiopathic anaemia, 233 ; diagnosis, 233 ; 
prognosis, 234 ; treatment, 234 ; diet, 234 ; attention to general hygiene, 
234 ; iron, 235 ; arsenic, 235 ; cold-water packing and massage, 236. 



CONTENTS. XI 

CHAPTER IV. 

PAGB 

Enlargement op the Spleen 237 

Causation of splenic enlargement, 237 ; simple hyperplasia, 238 ; morbid anat- 
omy, 238 ; symptoms, 238 ; anaemia, 238 ; oedema, 238 ; the blood, 239 ; 
cases, 239 ; gastro-intestinal troubles, 239 ; diagnosis, 240 ; prognosis, 
240 ; treatment, 240 ; abuse of mercurial frictions, 241. 

CHAPTER V. 

Hemophilia 242 

Causation, 242 ; morbid anatomy, 242 ; symptoms, 243 ; three grades, 243 ; 
haemorrhages, 243 ; joint auction, 244 ; .diagnosis, 245 ; prognosis, 245 ; 
treatment, 245. 

CHAPTER VL 

Purpura 247 

Two varieties, 247; causation, 247; morbid anatomy, 247; pathology, 248; 
symptoms, 248 ; eruption, 248 ; illustrative case, 249 ; pains in limbs, 
249 ; haemorrhagic purpura, 249 ; various haemorrhages, 249 ; purpura 
rheumatica, 249 ; anaemia, 250 ; temperature, 250 ; illustrative case, 250 ; 
oedema, 250 ; cerebral haemorrhage, 251 ; convulsions, 251 ; course, 251 ; 
diagnosis, 251 ; prognosis, 251 ; treatment, 251. 

CHAPTER VII. 

Scurvy 258 

Causation, 253 ; morbid anatomy, 254 ; periosteal extravasation, 254 ; pathol- 
ogy, 255 ; symptoms, 255 ; tenderness, 256 ; swelling, 256 ; petechiae, 256 ; 
separation of epiphyses, 256 ; the gums, 256 ; cachexia, 256 ; temperature, 
257 ; course, 257 ; diagnosis, 257 ; prognosis, 258 ; treatment, 258. 



JJart 5. 
DISEASES OF THE NEKYOUS SYSTEM. 

CHAPTER I. 

General -Considerations 260 

Excitability of the nervous system in early life, 260 ; value of various symp- 
toms, 261 ; squint, 261 ; nystagmus, 261 ; state of the pupils, 261 ; de- 
lirium, 262 ; drowsiness, 262 ; loss of consciousness, 262 ; changes of 
temper, 262 ; tremours, 263 ; spasms, 263 ; paralysis, 263 ; aphasia, 263 ; 
rigidity, 264 ; retraction of head, 264 ; vomiting, 264 ; the breathing, 
264 ; the pulse, 265 ; cerebral flush, 265 ; the urine, 265 ; hysterical 
symptoms, 265. 

CHAPTER II. 
Laryngismus Stridulus 267 

Causation, 267 ; association with rickets, 267 ; pathology, 268 ; exciting causes, 

268 ; illustrative case, 268 ; symptoms, 269 ; description of the seizure, 

269 ; duration of attacks, 269 ; illustrative case, 269 ; spasm limited to 
glottis, 270 ; characters of the spasm in new-born infants, 270 ; mode of 
death, 270 ; incarceration of epiglottis, 271 ; diagnosis, 271 ; prognosis, 
272 ; treatment, 272 ; ammonia, 272 ; cold bathing, 272 ; fresh air, 272 ; 
antispasmodics, 273 ; tonics, 273. 



Xll CONTENTS. 

CHAPTER III. 

PAGE 

Tonic Contraction of the Extremities 274 

Usually associated with laryngismus stridulus and reflex convulsions, 274 ; not 
uncommon in the subjects of rickets, 274 ; symptoms, 274 ; pain, 274 ; 
contraction of muscle, 274 ; usual seat, 274 ; influence of manipulation, 
275 ; is usually bilateral, 275 ; if severe, persists during sleep. 275 ; sen- 
sation unaffected, 275 ; diagnosis, 275 ; prognosis, 276 ; treatment, 276. 

CHAPTER IV. 
Convulsions a . 277 

Common during the first two years of life, 277 ; causation, 278 ; symptoms 
279 ; description of a paroxysm, 279 ; drowsiness, 280 ; temporary paral 
ysis, 280 ; congestion of brain, 280 ; illustrative case, 280 ; diagnosis, 281 
from cerebral convulsions, 281 ; from epilepsy, 282 ; prognosis, 283 ; in 
fluence on brain development, 283 ; treatment, 284 ; warm bath, 284 
chloral r 284 ; nitrite of amyl, 285 ; stimulants, 285 ; tonics, 285. 

CHAPTER V. 

Epilepsy . . „ 286 

Causation, 286 ; hereditary tendency, 286 ; injuries, 286 ; a fit of convulsions, 
286 ; illustrative case, 286 ; pathology, 287 ; symptoms, 288 ; epilepsia 
gravior, 288 ; epilepsia mitior, 288 ; a fit of epileptic vertigo, 288 ; illus- 
trative case, 289 ; frequency of attacks, 289 ; association with chorea, 
290 ; diagnosis, 290 ; from syncope, 290 ; from hysterical fits, 290 ; prog- 
nosis, 291 ; treatment, 291 ; general attention to health, 291 ; diet, 292 ; 
the bromides, 292 ; strychnia, 292 ; nitrite of amyl, 293. 

CHAPTER VI. 

Megrim 294 

Causation, 294 ; pathology, 294 ; symptoms, 295 ; headache, 295 ; impairment 
of sight, 295 ; of other senses, 295 ; illustrative case, 296 ; pains in limbs, 
296 ; illustrative case, 296 ; diagnosis, 296 ; treatment, 297 ; strychnia 
and ergot, 297. 

CHAPTER VII. 
Chorea 299 

Causation, 299 ; association with rheumatism, 299 ; pathology, 300 ; various 
theories, 300 ; symptoms, 301 ; disordered movements, 301 ; inco-ordina- 
tion of voluntary movement, 302 ; sleeplessness, 302 ; sensory disturb- 
ances, 302 ; hemichorea, 302 ; the urine, 303 ; mental state, 303 ; tem- 
perature, 303 ; weakness of muscle, 303 ; heart murmurs, 304 ; course 
and duration, 304 ; diagnosis, 304 ; prognosis, 304 ; treatment, 305 ; hy- 
giene, 305 ; moral treatment, 305 ; drugs, 305 ; massage, 306. 

CHAPTER VIII. 
Idiopathic Tetanus ; 308 

In infants, rare in England, 308 ; causation, 308 ; influence of general unsan- 
itary conditions, 309 ; morbid anatomy, 309 ; symptoms, 310 ; difficulty 
of swallowing, 310 ; stiffness of jaws, 310 ; temperature, 310 ; attacks of 
spasm, 310; tonic rigidity, 310; illustrative case, 310; duration, 311; 
tetanus in older children, 311 ; illustrative case, 311 ; diagnosis, 312 ; 
from strychnia poisoning, 312; prognosis, 312; treatment, 313; forced 
feeding, 313 ; Calabar bean, 313 ; chloral, 313 ; illustrative case, 314. 



CONTENTS. Xlll 

CHAPTER IX. 

PAGB 

Congestion of the Brain 316 

Circulation of blood in the brain, 316 ; causation, 316 ; two forms, 316 ; rela- 
tion to dentition, 316 ; and convulsions, 317 ; minute embolisms, 317 ; 
morbid anatomy, 317 ; symptoms, 318 ; irritative stage not clinically 
recognisable, 318 ; the common form, 318 ; illustrative case, 318 ; throm- 
bosis of cerebral sinuses, 319 ; diagnosis, 319 ; prognosis, 320 ; treatment, 
321. 

CHAPTER X. 

Cerebral Haemorrhage. 322 

Only common in still-born children, 322 ; causation, 322 ; sometimes the re- 
sult of aneurism of a cerebral artery, 322 ; morbid anatomy, 322 ; men- 
ingeal haemorrhage, 323 ; cerebral haemorrhage, 323 ; cause of aneurism, 
323 ; symptoms, 324 ; of meningeal haemorrhage, 324 ; low tempera- 
ture, 324 ; stupor and convulsions, 324 ; resemblance to simple menin- 
gitis, 325 ; illustrative case, 325 ; cerebral haemorrhage, 326 ; illustrative 
case, 326 ; haemorrhage from rupture of aneurism, 327 ; illustrative case, 
327 ; diagnosis, 328 ; prognosis, 329 ; treatment, 329. 

CHAPTER XL 

Cerebral Tumour , „ . . „ 330 

Cerebral growth usually tubercular, 330 ; morbid anatomy, 330 ; varieties of 
growths, 331 ; symptoms, 331 ; headache, 332 ; convulsions, 332 ; loss of 
special sense, 332 ; ophthalmoscopic appearances, 332 ; illustrative case, 
333 ; gliomatous tumour, 333 ; tubercular growth, 335 ; illustrative case, 
335 ; two stages often seen, 336 ; illustrative case, 336 ; cerebellar tumour, 
337 ; characteristic symptoms, 337 ; other seats, 337 ; diagnosis, 337 ; prog- 
nosis, 339 ; treatment, 339. 

CHAPTER XII. 

Chronic Hydrocephalus 340 

Causation, 340 ; morbid anatomy, 341 ; effect of pressure on the brain and 
skull, 341 ; symptoms, 342 ; distention of skull, 342 ; imperfect nutri- 
tion, 343 ; intelligence, 343 ; nervous symptoms, 343 ; illustrative case, 
343 ; the acquired form, 344 ; spontaneous evacuation of fluid, 344; diag- 
nosis, 345 ; prognosis, 345 ; treatment, 345. 

CHAPTER XIII. 

Otitis and its Consequences 346 

Extension of inflammation from the tympanum to the skull cavity, 346 ; cau- 
sation, 346 ; morbid anatomy, 347 ; symptoms, 348 ; extension of inflam- 
mation to the meninges, 348 ; purulent meningitis, 349 ; temperature, 
349 ; convulsions, 349 ; illustrative case, 349 ; phrenitic form, 350 ; de- 
lirium, 350 ; temperature, 350 ; thrombosis of the cerebral sinuses, 351 ; 
encephalitis, 351 ; convulsions, 351 ; stupor, 351 ; paralysis, 351 ; illus- 
trative case, 352; diagnosis, 352; prognosis, 354; treatment, 354. 

CHAPTER xiy. 

Tubercular Meningitis 355 

Common at all ages of childhood, 355 ; causation, 355 ; morbid anatomy. 356; 
symptoms, 357 ; premonitory, 357 ; two forms, 357 ; primary meningitis, 
357 ; three stages, 358 ; first stage, 358 ; second stage, 359 ; third stage, 
360 ; duration of illness, 361 ; secondary meningitis, 361 ; common in 
infants, 362 ; anomalous cases, 362 ; diagnosis, 362 ; illustrative case, 
363 ; prognosis, 365 ; treatment, 365. 



Xiv CONTENTS. 

CHAPTER XV. 

PAGE 

Paralysis of the Portio Dura 367 

Course of the facial nerve in the Fallopian canal, 367 ; causation of the par- 
alysis, 367 ; symptoms, 368 ; illustrative case, 368 ; diagnosis and prog- 
nosis, 369 ; treatment, 370. 

CHAPTER XVI. 

Acute Infantile Spinal Paralysis 371 

Causation, 371 ; morbid anatomy, 372 ; symptoms, 373 ; onset, 373 ; com- 
pleteness of the paralysis, 374 ; rapid limitation of the paralyzed area, 
374 ; wasting of muscles, 375 ; stage of contraction, 375 ; mechanism of 
the deformities, 375 ; diagnosis, 377 ; prognosis, 377 ; treatment, 378. 

CHAPTER XVII. 
Spasmodic Spinal Paralysis 380 

Morbid anatomy, 380 ; symptoms, 380 ; rigidity of joints, 381 ; diagnosis, 
382 ; prognosis, 382 ; treatment, 382. 

CHAPTER XVIII. 

Pseudo-hypertrophic Paralysis 384 

Causation, 384 ; morbid anatomy, 384 ; symptoms, 385 ; enlargement of mus- 
cles, 385 ; progressive weakness, 385 ; occasional atrophy of muscle, 386 ; 
contractions, 386 ; course, 387 ; diagnosis, 387 ; prognosis, 388 ; treat- 
ment, 388. 

CHAPTER XIX. 
Idiocy 2 

Causation, 389 ; morbid anatomy, 390 ; classification, 391 ; symptoms, 391 ; 
cretinism, 392 ; illustrative cases, 393 ; degrees of mental development, 

394 ; diagnosis, 395 ; development of the senses in the healthy infant, 

395 ; prognosis, 396 ; treatment, 397. 



Jkvt 6. 

DISEASES OF THE OKGANS OF KESPIEATIOK 

CHAPTER I. 
Examination of the Chest 399 

Position of the patient during examination, 399 ; inspection, 399 ; shape of 
the chest, 400 ; movements in respiration, 400 ; retraction of the chest, 
400 ; enlargement, 401 ; palpation. 401 ; vocal fremitus, 401 ; friction 
fremitus, 401 ; site of apex-beat of heart, 401 ; causes of its displacement, 
402 ; level of the liver and spleen, 402 ; percussion, 402 ; degree of re- 
sistance, 403 ; auscultation, 403 ; conduction of sounds, 4C4. 

CHAPTER II. 
Laryngitis 406 

Simple laryngitis, 406 ; causation, 406 ; morbid anatomy, 406 ; mild form, 
407 ; severe form, 407 ; illustrative case, 408 ; chronic laryngitis, 408 ; 
diagnosis, 408 ; case of hysterical aphonia, 409 ; prognosis, 410 ; treat- 
ment, 410 ; stridulous laryngitis, 411 ; causation, 411 ; morbid anatomy, 

411 ; symptoms, 412 ; dyspnoea, 412 ; croupy cough, 412 ; temperature, 

412 ; illustrative case, 412 ; carpo-pedal contractions, 413 ; diagnosis, 413 ; 
prognosis, 414 ; treatment, 414 ; tubercular laryngitis, 415 ; causation, 
415 ; symptoms, 416 ; illustrative case, 416 ; diagnosis, 417 ; case of 
warty growths on larynx, 417 ; prognosis, 418 ; treatment, 418. 



CONTENTS. XV 

CHAPTER III. 

PAGE 

Suppuration about the Larynx 419 

Causation, 419 ; morbid anatomy, 419 ; symptoms, 419 ; ortliopnoea, 419 ; sup- 
pressed voice, 420 ; diagnosis, 420 ; prognosis, 421 ; treatment, 421. 

CHAPTER IV. 

Croupous Pneumonia , 422 

Causation, 422 ; nature of the disease, 422 ; sometimes secondary, 423 ; mor- 
bid anatomy, 423 ; symptoms, 424 ; onset, 424 ; temperature, 424 ; cough, 
424 ; muscular weakness, 425 ; nervous symptoms, 425 ; illustrative case, 
426 ; breathing, 426 ; pulse-respiration ratio, 426 ; digestive organs, 426 ; 
urine, 426 ; pyrexia, 426 ; occasional dyspnoea, 427 ; physical signs, 427 ; 
their seat, 428 ; terminations, 428 ; resolution. 428 ; abscess of the lung, 

429 ; latent form of pneumonia, 429 ; complications, 430 ; plastic pleurisy, 

430 ; pericarditis, 43l> ; jaundice, 430 ; diagnosis, 430 ; prognosis, 431 ; 
treatment, 432 ; diet, 432 ; reduction of pyrexia, 432 ; tepid bathing, 432 ; 
quinine, 432 ; value of bleeding, 433 ; stimulants, 433. 

CHAPTER V. 

Catarrhal Pneumonia 434 

Causation, 434 ; morbid anatomy, 434 ; symptoms, 436 ; always secondary to 
pulmonary catarrh, 436 ; temperature, 436 ; pulse-respiration ratio, 437 ; 
breathing, 437 ; cough, 437 ; physical signs, 437 ; terminations, 438 ; sub- 
acute course, 438 ; complications, 439 ; diagnosis, 439 ; from croupous 
pneumonia, 440 ; exclusion of tuberculosis, 440 ; acute dilatation of 
bronchi, 441 ; prognosis, 441 ; treatment, 441 ; tepid bathing, 441 ; 
counter-irritation of chest, 442 ; stimulants, 442 ; diet, 442 ; emetics, 
442 ; iron, 443. 

CHAPTER VI. 

Pleurisy 444 

Causation, 444 ; morbid anatomy, 444 ; characters of effusion, 445 ; symptoms, 
445 ; onset, 445 ; pyrexia, 446 ; pain, 446 ; complexion, 446 ; empyema, 
447 ; physical signs, 447 ; inspection, 447 ; percussion, 448 ; auscultation, 
449 ; friction-sound, 449 ; occasional symptoms, 449 ; spontaneous evacu- 
ation, 450 ; perforation of bronchus, 450 ; illustrative case. 451 ; varieties, 
451 ; plastic pleurisy, 452 ; loculated form, 452 ; tuberculous form, 452 ; 
complications, 453 ; diagnosis, 453 ; from croupous pneumonia, 453 ; 
from catarrhal pneumonia, 454 ; from collapse of lung, 454 ; of empyema, 
455 ; of hydrothorax, 455 ; prognosis, 455 ; treatment, 456 ; iodide of 
potassium, 456 ; aspiration, 457 ; illustrative case, 457 ; causes of sudden 
death, 458 ; use of the drainage-tube, 459 ; resection of rib, 460 ; diet, 
460. 

CHAPTER YIL 

Collapse of the Lung 461 

Two varieties, 461 ; congenital atelectasis, 461 ; morbid anatomy, 461 ; symp- 
toms. 462 ; prostration, 462 ; lividity, 462 ; temperature, 462 ; feeble res- 
piration, 462 ; trifling physical signs, 462 ; drowsiness, 462 ; signs of re- 
covery sometimes deceptive, 463 ; diagnosis, 463 ; prognosis, 463 ; treat- 
ment, 463 ; artificial respiration, 464 ; hot bath, 464 ; counter-irritation, 
464 ; stimulants, 464 ; post-natal atelectasis, 465 ; causation, 465 ; morbid 
anatomy, 466 ; symptoms, 467 ; lividity, 467 ; feeble, rapid breathing, 
467 ; temperature, subnormal, 467 ; perverted pulse-respiration ratio, 
467 ; physical signs, 467 ; symptoms during second year, 468 ; illustra- 
tive case, 469 ; diagnosis, 469 ; prognosis, 471 ; treatment, 471 ; warmth, 
471 ; emetics, 471 ; stimulants, 471. 



Xvi CONTENTS. 



CHAPTER VIII. 

PAGE 

Fibroid Induration of the Lung 473 

Pathology, 473 ; morbid anatomy, 474 ; amyloid degenerations, 475 ; symp- 
toms, 475 ; early stage, 475 ; physical signs oi established disease, 476 ; 
symptoms, 476 ; cough, 476 ; offensive sputum, 477 ; nutrition, 477 ; 
temperature, 477 ; hypertrophy of right ventricle of heart, 477 ; contrac- 
tion of side, 477 ; fibroid phthisis, 477 ; diagnosis, 478 ; from pleurisy 
with retraction, 478 ; from phthisis, 478 ; prognosis, 479 ; treatment, 
479 ; diet, 479 ; tonics, 480. 

CHAPTER IX. 
Bronchitis 481 

Causation, 481 ; morbid anatomy, 482 ; symptoms, 482 ; of bronchial catarrh, 
483 ; the mild form, 483 ; the severe form, 483 ; capillary bronchitis, 
483 ; temperature, 483 ; dyspnoea, 483 ; pulse, 484 ; physical signs. 484 ; 
signs of asphyxia, 484 ; chronic bronchitis, 484 ; symptoms, 485 ; illustra- 
tive case, 485 ; diagnosis, 485 ; prognosis, 486 ; treatment, 486 ; counter- 
irritation, 486 ; diaphoretics, 487 ; stimulant expectorants injurious at the 
first, 487 ; after-treatment, 488 ; treatment of chronic bronchitis, 489. 



CHAPTER X. 

Emphysema : 491 

Causation, 491 ; morbid anatomy, 492 ; two varieties, 492 ; inter-lobular and 
vesicular, 493 ; symptoms, only present in the vesicular form, 493 ; phys- 
ical signs, 493 ; illustrative cases, 494 ; diagnosis, 494 ; prognosis, 494 ; 
treatment, 495. 

CHAPTER XI. 

Gangrene op the Lung 496 

Rarity in childhood, 496 ; causation, 496 ; morbid anatomy, 497 ; symptoms, 
497 ; onset, gradual or sudden, 498 ; prostration and restlessness, 498 ; 
pulse, 498 ; respiration, 498 ; temperature, 498 ; fetid breath and expec- 
toration, 498 ; dyspnoea, 498 ; haemoptysis, 499 ; physical signs, 499 ; il- 
lustrative case, 499 ; diagnosis, 499 ; prognosis, 500 ; treatment, 500 ; 
antiseptic inhalations, 500 ; stimulants, 501 ; diet, 501. 

CHAPTER XII. 
Pulmonary Phthisis 502 

Varieties, 502 ; causation, 502 ; communicability of the disease, 503 ; morbid 
anatomy, 504 ; acute phthisis, 505 ; symptoms, 505 ; dyspnoea, 506 ; tem- 
perature, 506 ; physical signs, 506 ; illustrative case, 506 ; mode of death, 
507 ; duration, 507 ; prognosis, 507 ; chronic pneumonic phthisis, 508 ; 
mode of beginning, 509 ; stage of softening, 509 ; cough, 509 ; haemopty- 
sis, 510 ; temperature, 510 ; physical signs, 510 ; ulceration of bowels, 

510 ; secondary catarrhal pneumonia, 510 ; mode of death, 511 ; chronic 
tubercular phthisis, 511 ; wasting, 511 ; temperature. 511 ; physical signs, 

511 ; advantages of removing diseased bone, 512 ; illustrative case, 512 ; 
occasional obscurity of physical signs, 513 ; diagnosis, 513 ; of dilated 
bronchi, 514 ; from empyema, 514 ; prognosis, 515 ; treatment, 516 ; pre- 
ventive treatment, 516 ; treatment of acute phthisis, 516 ; reduction of 
temperature, 516 ; regular feeding, 517 ; treatment of chronic phthisis, 
517 ; diet, 517 ; change of air, 517 ; antiseptic inhalations, 518 ; sedatives 
and expectorants, 518 ; necessity of attention to the digestive organs, 518. 



CONTENTS. XV11 

CHAPTER XIII. p AGE 

Paroxysmal Dyspncea 519 

Definition of dyspnoea, 519 ; causes which produce it, 519 ; obstruction of 
wind-pipe, 519 ; of pulmonary artery, 519 ; disease of heart, 519 ; ex- 
ternal pressure upon lung, 519 ; by fluid in pleura, 519 ; by the atmos- 
phere in rickets, 519 ; disease of lung, 519 ; causes of paroxysmal dysp- 
noea, 520 ; bronchial asthma, 520 ; its causes, 520 ; its symptoms, 521 ; 
its physical signs, 521 ; diagnosis, 521 ; of enlarged bronchial glands, 522 ; 
of foreign body in the air tubes, 523 ; of bronchial asthma, 523 ; prog- 
nosis, 524 ; treatment, 524. 

CHAPTER XIV. 

Foreign Bodies in the Air-tubes 526 

Morbid anatomy, 526; symptoms, 527; dyspnoea, 527; spasmodic cough, 
527 ; pain in the chest, 528 ; physical signs, 528 ; spontaneous expulsion, 
529 ; gangrene of lung, 529 ; illustrative case, 529 ; seat of the foreign 
body, 530 ; in the larynx, 530 ; in the trachea, 531 ; in the bronchus, 
531 ; diagnosis, 531 ; from spasmodic laryngitis, 532 ; from membranous 
croup, 533 ; prognosis, 533 ; treatment, 533. 



JJart 7. 
DISEASES OF THE HEAKT. 

CHAPTER I. 

Congenital Heart Disease 535 

Normal development of the heart, 535 ; arrest of development, 536 ; varieties 
of malformation, 536 ; morbid anatomy, 537 ; symptoms, 538 ; cyanosis, 
538 ; shape of chest, 538 ; temperature, 538 ; dyspnoea, 538 ; oedema, 
538 ; urine, 539 ; digestive organs, 539 ; the commonest form of mal- 
formation, 539 ; nutrition, 539 ; disease of the petrous bone, 540 ; con- 
vulsions, 540 ; duration of life, 540 ; mode of death, 540 ; diagnosis, 540 ; 
prognosis, 542 ; treatment, 542. 

CHAPTER II. 

Chronic Valvular Disease of the Heart 544 

Causation, 544 ; rheumatism, 544 ; chorea. 544 ; syphilis, 545 ; morbid anat- 
omy, 545 ; valvular lesions, 545 ; adhesion of pericardium, 546 ; Par- 
rot's haematomata, 546 ; hypertrophy and dilatation of walls, 546 ; 
symptoms, 547 ; dyspnoea, 547 ; palpitation, 547 ; haemorrhages, 547 ; 
embolisms, 547 ; of brain, 548 ; illustrative case, 548 ; symptoms due to 
the rheumatic disposition, 549 ; impairment of nutrition, 549 ; relative 
irequency of the various forms, 549 ; terminations, 550 ; cardiac dropsy, 
550 ; clotting of blood in the heart, 550 ; illustrative cases, 550 ; diagno- 
sis, 550 ; occasional disappearance of murmur, 551 ; prognosis, 552 ; 
treatment, 552 ; digitalis, 553 ; aperients, 553 ; diet, 553 ; diuretics, 553. 



Part 8. 
DISEASES OF THE MOUTH AND THROAT. 

CHAPTER I. 

The Derangements of Teething 555 

Teething not a morbid process, 555 ; eruption of the milk-teeth, 556 ; natural 
order, 557 ; irregularities, 557 ; symptoms of teething, 558 ; temperature, 



xviii CONTENTS. 



558 ; complications, 558 ; stomatitis, 559 ; digestive troubles, 559 ; pul- 
monary catarrh, 559 ; otitis, 560 ; skin diseases, 560 ; nervous disorders, 
560 ; the second dentition, 560 ; order of eruption, 560 ; diagnosis, 561 ; 
treatment, 561 ; value of lancing the gums, 562 ; treatment of " night 
terrors," 562. 

CHAPTER II. 
Stomatitis 563 

Aphthous stomatitis, 563 ; symptoms, 563 ; diagnosis, 564 ; prognosis, 564 ; 
treatment, 564. Ulcerative stomatitis, 564 ; causation, 564 ; symptoms, 
565 ; diagnosis, 566 ; prognosis, 566 ; treatment, 566 ; value of chlorate 
of potash, 566. 

CHAPTER III. 

Gangrenous Stomatitis 567 

Causation, 567; morbid anatomy, 567; symptoms, 568 ; duration, 569 ; prog- 
nosis, 569 ; treatment, 569 ; diet and stimulants, 569 ; caustics, 570 ; 
quinine and iron, 570. 

CHAPTER IV. 

Thrush 571 

Causation, 571 ; morbid anatomy, 572 ; the oidium albicans, 572 ; its seat, 
572 ; symptoms, 573 ; in mild cases, 573 ; in severe cases, 573 ; local 
symptoms, 573 ; general symptoms, 573 ; diagnosis, 574 ; prognosis, 574 ; 
treatment, 574. 

CHAPTER V. 

Pharyngitis 576 

Simple pharyngeal catarrh, 576 ; causation, 576 ; symptoms, 576 ; scald of 
throat, 577 ; diagnosis, 577 ; treatment, 577 ; of scald, 578. Follicular 
pharyngitis, 578 ; causation, 578 ; morbid anatomy, 578 ; symptoms, 578 ; 
deafness, 579 ; appearance of fauces, 579 ; diagnosis, 579 ; prognosis, 579 ; 
treatment, 579 ; local applications, 580 ; caustics, 580. Herpes of the 
pharynx, 580 ; causation, 580 ; symptoms, 580 ; diagnosis, 580; treat- 
ment, 581. Tubercular pharyngitis, 581 ; morbid anatomy, 581 ; symp- 
toms, 581 ; appearance of fauces, 581 ; ulceration of throat, 582 ; often 
extensive, 582 ; temperature, 582 ; pain in swallowing, 582 ; implication 
of lungs, 582 ; diagnosis, 582 ; from syphilitic ulceration, 582 ; prognosis, 
583 ; treatment, 583. 

CHAPTER VI. 

Quinsy 584 

Nature of the disease, 584 ; causation, 584 ; morbid anatomy, 585 ; symptoms, 
585 ; pain, 585 ; temperature, 585 ; formation of abscess, T86 ; duration, 
586 ; the non-suppurative form, 566 ; chronic enlargement of tonsils, 586 ; 
their influence on the general health, 587 ; alteration of features, 587 ; de- 
formity of chest, 587 ; cough, 588 ; diagnosis, 588 ; prognosis, 588 ; treat- 
ment, 588 ; aconite, 588 ; salicylate of soda, 588 ; local applications, 589 ; 
diet, 589 ; treatment of chronic enlargement, 589 ; excision, 590 ; caus- 
tics, 590. 

CHAPTER VII. 

Retro-pharyngeal Abscess 591 

Causation, 591 ; morbid anatomy, 591 ; symptoms, 592 ; dysphagia, 592 ; 
dyspnoea, 592 ; cough, 592 ; acute form, 593 ; chronic form, 593 ; illus- 
trative case, 593 ; terminations, 594 ; diagnosis. 594 ; from membranous 
croup, 594 ; from oedema of glottis, 594 ; prognosis, 595 ; treatment, 595. 



CONTENTS. XIX 

|Jart 9. 
DISEASES OF THE DIGESTIVE OEGANS. 

CHAPTER I. 

PAGE 

Infantile Atrophy 596 

Causation, 596 ; due to insufficient nourishment, 596 ; cow's milk often indi- 
gestible, 597 ; reason of this, 597 ; analysis of various milks, 597 ; diffi- 
culty of digesting starch in early infancy, 598 ; liability to catarrh in 
early life, 598 ; occasional indigestibility of breast-milk, 599 ; illustrative 
case, 599 ; morbid anatomy of atrophy, 600 ; symptoms, 600 ; wasting, 
600 ; signs of indigestion, 600 ; eruptions on the skin, 601 ; colic, 601 ; 
constipation, 601 ; vomiting, 601 ; diarrhoea, 602 ; diagnosis, 602 ; from 
infantile syphilis, 602 ; from acute tuberculosis, 602 ; prognosis, 6C3 ; 
treatment, 603 ; rules for the hand-feeding of infants, 604 ; preparation 
of cow's milk, 606 ; pancreatised milk, 606 ; artificial human milk, 606 ; 
treatment of obstinate vomiting, 607 ; illustrative cases, 607 ; necessity of 
vigilance, 608. 

CHAPTER II. 
Gastric Catarrh , 609 

Causation, 609 ; morbid anatomy, 610 ; symptoms, 610 ; acute febrile form, 

610 ; temperature, 610 ; signs of general catarrh, 610 ; recurring attacks, 

611 ; their influence upon general nutrition, 611 ; the non-febrile variety, 
611 ; sallow complexion, 611 ; languor, 611 ; flatulence, 611 ; nervous 
movements, 611 ; headache, 611 ; uric acid and urates in urine, 611 ; 
tongue, 612 ; fainting fits, 612 ; diagnosis, 612 ; illustrative cases, 613 ; 
treatment, 615 ; diet, 615 ; tonics, 615 ; warmth to the belly, 616 ; baths, 
616. 

CHAPTER IIL 
Constipation 617 

Causation, 617 ; symptoms, 619 ; in infants, 619 ; in older children, 619 ; im- 
paction of faeces, 619 ; may prove fatal, 620 ; diagnosis, 620 ; treatment, 
621 ; in infants, 621 ; aperients, 621 ; pepsin, 622 ; enemata, 622 ; treat- 
ment of colic, 622 ; in older children, 623 ; treatment of impaction of 
faeces, 623. 

CHAPTER IV. 

Diarrhoea . 624 

Varieties, 624 ; causation of simple diarrhoea, 624 ; morbid anatomy, 625 ; 
symptoms, 625 ; character of the stools, 626 ; lienteric diarrhoea, 626 ; 
treatment, 626 ; of lienteric diarrhoea, 628. 

CHAPTER V. 

Inflammatory Diarrhgsa 629 

Causation, 629 ; morbid anatomy, 630 ; symptoms, 630 ; in infants, 630 ; char- 
acter of stools, 630 ; frequency of motions, 631 ; their microscopic appear- 
ances, 631 ; general symptoms, 631 ; temperature, 631 ; illustrative cases, 

631 ; catarrh of colon, 631 ; tenesmus, 632 ; blood in stools, 632 ; com- 
plications, 632 ; parenchymatous nephritis, 632 ; spurious hydrocephalus, 

632 ; in children after infancy, 632 ; general symptoms, 632 ; tempera- 
ture, 633 ; the urine, 633 ; early prostration, 633 ; the chronic form, 633 ; 
insidious beginning, 633 ; pasty stools, 633 ; gradual wasting, 633 ; diar- 
rhoea, 634 ; oedema, 634 ; diagnosis, 634 ; of seat of catarrh, 634 ; Professor 
Nothnagel's researches, 634 ; prognosis, 635 ; treatment, 636 ; diet, 636 ; 
warmth, 636 ; ventilation, 636 ; cold or tepid bathing, 637 ; illustrative 
case, 637 ; remedies, 637 ; value of astringents, 638 ; of ipecacuanha, 638 ; 
of opium, 638 ; treatment of acute prolapsus ani, 639 ; of spurious hydro- 
cephalus, 639 ; of chronic diarrhoea, 640 ; value of raw meat, 640. 



XX CONTENTS. 

CHAPTER VI. 

PAGE 

Choleraic Diarrhoea (Infantile Cholera) 642 

Causation, 642 ; morbid anatomy, 642 ; symptoms, 642 ; vomiting, 643 ; diar- 
rhoea, 643 ; character of stools, 643 ; rapid wasting, 643 ; excessive thirst, 
643 ; temperature, 643 ; exhaustion, 644 ; occasional recovery, 644 ; dura- 
tion, 644 ; diagnosis, 644 ; prognosis, 644 ; treatment, 644 ; abundant 
liquid, 644 ; food, 644 ; koumiss, 644 ; white wine whey, 645 ; drugs, 
645 ; hypodermic injection of morphia, 645 ; illustrative case, 646. 

CHAPTER VII. 

Dysentery 647 

Causation, 647 ; morbid anatomy, 647 ; sloughing of mucous membrane, 648 ; 
abscesses in liver, 648 ; symptoms, 648 ; tenesmus, 648 ; mucus, 648 ; 
blood, 648 ; colic, 649 ; character of stools, 649 ; their offensive odour, 649 ; 
temperature, 650 ; mode of death, 650 ; chronic form, 650 ; diagnosis, 
650 ; prognosis, 651 ; treatment, 651 ; value of opium, 651 ; of ipecacu- 
anha, 651 ; of mercury, 652 ; special treatment for infants, 652 ; astrin- 
gent injections, 653 ; diet, 653 ; treatment of the chronic form, 653 ; diet 
during convalescence, 653. 

CHAPTER VIII. 

Gastro-intestinal Haemorrhage 654 

Spurious hsematemesis, 654 ; its causes, 654 ; causes of the real haemorrhage, 
654 ; melaena neonatorum, 654 ; its causes, 655 ; haemorrhage in older 
children, 655 ; causes, 655 ; general, 655 ; local, 655 ; polypus of rectum, 

656 ; symptoms of gastro-intestinal|Jiaemorrhage, 656 ; of melaena neona- 
torum, 656 ; of haemorrhage in later childhood, 657 ; of polypus of rectum, 

657 ; diagnosis, 657 ; prognosis, 658 ; treatment, 659. 

CHAPTER IX. 

Ulceration op the Bowels 660 

Varieties of ulcer, 660 ; morbid anatomy, 660 ; symptoms, 661 ; often obscure, 
661 ; pain in abdomen, 661 ; tenderness, 661 ; tension of parietes, 661 ; 
the stools. 662 ; haemorrhage, 662 ; state of nutrition, 662 ; complications, 
663 ; illustrative case, 663 ; diagnosis, 664 ; of nature of ulceration, 665 ; 
prognosis, 665 ; treatment, 666 ; diet, 666 ; value of raw meat, 666 ; of 
malted bread, 666 ; milk inadmissible, 666 ; stimulants, 667 ; drugs, 667 ; 
nitrate of silver, 667 ; opium, 667 ; astringent injections, 667 ; pepsin, 
667. 

CHAPTER X. 
Intestinal Obstruction (Intussusception) 668 



Varieties of obstruction, 668 ; intussusception, 668 ; causation, 668 ; morbid 
anatomy, 668 ; symptoms, 670 ; in infants, 670 ; pain, 670 ; straining, 

670 ; discharge of blood, 670 ; constipation, 670 ; temperature, 670 ; col- 
lapse, 671 ; in older children, 671 ; distention of belly, 671 ; vomiting, 

671 ; melaena not always present, 671 ; signs of prostration, 671 ; separa- 
tion of gangrenous segment, 672 ; mode of death, 672 ; special symptoms, 

672 ; swelling in the abdomen, 673 ; temperature, 673 ; duration, 673 ; 
diagnosis, 673 ; from simple colic, 674 ; from peritonitis, 674 ; from dys- 
entery, 674 ; from impaction of faecal matter, 675 ; prognosis, 675 ; treat- 
ment, 675 ; injections of water, 676 ; insufflation of air, 676 ; taxis, 676 ; 
surgical interference, 677. 









CONTENTS. XXI 



CHAPTER XL 

PAGE 

Typhlitis and Perityphlitis 678 

Causation, 678 ; symptoms, 679 ; of typhlitis, 679 ; of perityphlitis, 679 ; per- 
foration of bowel, 679 ; extravasation into peritoneum, 679 ; suppuration 
behind caecum, 680 ; simulation of hip-joint disease, 680 ; post-csecal ab- 
scess, 680 ; illustrative case, 681 ; perforation of vermiform appendix, 
682 ; diagnosis, 682 ; of typhlitis, 682 ; of perityphlitis, 683 ; of perfora- 
tion of the vermiform process, 683 ; prognosis, 683 ; treatment, 684 ; 
aperients hurtful, 684 ; diet, 684. 

CHAPTER XII. 

Acute Peritonitis 685 

Causation, 685 ; morbid anatomy, 686 ; symptoms, 686 ; of the primary form, 
686 ; vomiting, 687 ; pain and tenderness, 687 ; temperature, 687 ; dis- 
tention of belly, 687 ; fluctuation, 687 ; looseness of bowels, 687 ; the 
secondary form, 688 ; the latent form, 688 ; diagnosis, 689 ; from the 
tuberculous form, 689 ; from colic, 689 ; from rheumatism of the abdom- 
inal wall, 689 ; visceral peritonitis, 690 ; illustrative case, 690 ; prognosis, 
691 ; treatment, 691 ; opium, 691 ; leeches, 691 ; warmth to the belly, 
691 ; diet, 691 ; treatment of tympanitis, 692. 

CHAPTER XIII. 

Tubercular Peritonitis 693 

Morbid anatomy, 693 ; symptoms, 694 ; of the chronic form, 694 ; insidious 
beginning, 694 ; illustrative case, 694 ; tenderness of abdomen, 694 ; dis- 
tention, 695 ; unequal resistance of belly, 695 ; obscure fluctuation, 695 ; 
temperature, 695 ; rapid wasting, 696 ; occasional improvement, 696 ; 
the acute form, 696 ; illustrative case, 696 ; diagnosis, 697 ; of the 
chronic form, 698 ; of acute form, 698 ; prognosis, 698 ; treatment, 698 ; 
warmth to belly, 698 ; opium, 699 ; of the diarrhoea, 699 ; diet, 699. 

CHAPTER XIV. 

Ascites 700 

Causation, 700 ; symptoms, 700 ; distention of belly, 700 ; fluctuation, 701 ; 
percussion dulness in flanks, 701 ; occasional dyspnoea, 701 ; other symp- 
toms according to cause, 701 ; diagnosis, 702 ; illustrative case, 702 ; from 
hydronephrosis, 703 ; prognosis, 703 ; treatment, 704 ; paracentesis, 704. 

CHAPTER XV. 

Intestinal Worms 705 

Varieties, 705 ; description, 706 ; mode of entrance into body, 707 ; symp- 
toms, general, 708 ; special, of thread-worms, 709 ; of lumbrici, 709 ; 
nocturnal diarrhoea, 710 ; their migrations, 710 ; of tape-worm. 711 ; di- 
agnosis, 711 ; treatment, 711 ; of thread-worms, 711 ; of lumbrici, 712 ; 
of tape-worm, 712 ; various vermifuges, 712. 



13 art la. 

DISEASES OF THE LIVEE. 

CHAPTER I 
Jaundice 714 

In infants (icterus neonatorum), 714 ; true and false jaundice, 714 ; symp- 
toms of icterus, 715 ; causes, 716 ; from congenital malformation of bile- 
ducts, 716 ; cirrhosis of liver, 717 ; haemorrhage from navel, 717 ; illus- 



XX11 CONTENTS. 

PAGE 

trative case, 718 ; from syphilitic inflammation of the liver, 718 ; from 
umbilical phlebitis (icterus malignus), 718 ; jaundice in childhood, 719 ; 
causes, 719 ; diagnosis, 719 ; prognosis, 720 ; treatment, 720. 

CHAPTER II. 

Congestion of the Liver 722 

Causation, 722 ; morbid anatomy, 722 ; symptoms, 723 ; sense of weight in 
side, 723 ; dyspeptic symptoms, 723 ; light-coloured stools, 723 ; diagnosis, 
723 ; illustrative case, 724 ; prognosis, 724 ; treatment, 724 ; diet, 724. 

CHAPTER III. 

Cirrhosis op the Liver 726 

Causation, 726 ; morbid anatomy, 726 ; two varieties, 726 ; symptoms, 727 ; 
of atrophic cirrhosis, 727 ; indigestion, 727 ; ascites, 728 ; earthy tint of 
skin, 728 ; haemorrhages, 728 ; of hypertrophic cirrhosis, 728 ; jaundice, 
728 ; enlargement of liver, 728 ; diagnosis, 729 ; prognosis, 729 ; treat- 
ment, 730 ; aperients, 730 ; paracentesis, 730. 

CHAPTER IV. 

Amyloid Liver 731 

Causation, 731 ; morbid anatomy, 731 ; symptoms, 731 ; enlargement of liver 
731 ; absence of pain or tenderness, 732 ; digestive disturbance, 732 
anaemia, 732 ; oedema, 732 ; kidneys and spleen often implicated, 732 
diagnosis, 732 ; prognosis, 733 ; occasional complete recovery, 733 ; treat- 
ment, 733 ; iodine, 733 ; iron, 733 ; liberal diet, 734 ; sea air, 734. 

CHAPTER V. 

Fatty Liver 735 

Causation, 735 ; two forms, 735 ; morbid anatomy, 735 ; symptoms of fatty 
infiltration, 735 ; enlargement, 735 ; occasional tenderness, 736 ; diag- 
nosis, 736 ; prognosis, 736 ; treatment, 736. 

CHAPTER VI. 

Hydatid op the Liver 737 

Causation, 737 ; morbid anatomy, 737 ; description of the taenia echinococcus, 
737 ; symptoms, 738 ; swelling in liver, 739 ; rarely jaundice or ascites, 
739 ; illustrative case, 739 ; termination if left alone, 740 ; diagnosis, 740 ; 
prognosis, 741 ; treatment, 741 ; paracentesis, 742 ; illustrative case, 742 ; 
treatment by electrolysis, 742. t 



Part 11. 
DISEASES OF THE GENITO-UKINAKY OKGANS. 

CHAPTER I. 
The Urine 744 

Characters of the urine in health, 744 ; variations in its quantity, 744 ; their 
causes, 745 ; variations in the quantity of solid matters, 745 ; of urea, 
745 ; causes of lithates, 745 ; albuminuria, 746 ; its causes, 746 ; hsema- 
turia, 746 ; its causes, 746 ; from irritation of the passages by the bilhar- 
zia haematobia, 747 ; retention of urine, 748 ; its causes, 748 ; nocturnal 
incontinence of urine, 748 ; its nature, 749 ; and treatment, 750. 



CONTENTS. XX111 



CHAPTER II. 

PAGE 

Chronic Bright's Disease 752 

Causation, 752 ; morbid anatomy, 753 ; the granular kidney, 753 ; the fatty 
kidney. 753 ; the amyloid kidney, 753 ; symptoms, 754 ; illustrative 
case, 754 ; anaemia, headache and vomiting, 755 ; acute exacerbations, 
755 ; illustrative case, 755 ; insidious progress of the granular kid- 
ney, 756 ; illustrative case, 756 ; the amyloid kidney, 758 ; renal inade- 
quacy, 758 ; sometimes seen in young infants, 758 ; diagnosis of renal 
disease, 759 ; prognosis, 760 ; treatment, 760 ; diet, 760 ; aperients, 761 ; 
especially valuable in uraemia, 761 ; diaphoretics, 761 ; iron, 761 ; treat- 
ment of chronic albuminuria, 762. 

CHAPTER III. 
Calculus of the Kidney 763 

Sand in the urine common in children, 763 ; formation of uric acid in urine, 

763 ; formation of oxalate of lime, 764 ; causation of calculus of kidney, 

764 ; symptoms, 764 ; haematuria, 765 ; pain in loins, 765 ; illustrative 
case, 765 ; renal colic, 766 ; impaction of stone in ureter, 766 ; stone in 
bladder, 766 ; diagnosis of calculus of kidney, 767 ; illustrative case, 767 ; 
prognosis, 768 ; treatment, 768 ; diet, 768 ; alkalis, 768. 

CHAPTER IV. 

Tumours of the Kidney 770 

Sarcoma of kidney, 770 ; morbid anatomy, 770 ; symptoms, 770 ; swelling of 
abdomen, 770 ; signs of pressure, 771 ; illustrative case, 771 ; duration, 
772 ; hydronephrosis, 772 ; causation, 772 ; symptoms, 772 ; painless 
tumour, 772 ; fluctuation, 773 ; diagnosis of renal tumours, 773 ; treatment 
of hydronephrosis, 774. 

CHAPTER V. 

Vulvitis 775 

Two forms, 775 ; causation, 775 ; symptoms, 775 ; of catarrhal vulvitis, 775 ; 
of aphthous vulvitis, 776 ; diagnosis, 776 ; treatment, 776 ; of catarrhal 
vulvitis, 776 ; of aphthous vulvitis, 777. 



JJart 12. 

DISEASES OF THE SKIK 



CHAPTER I. 

Diseases of the Skin 778 

The papular eruptions, 778 ; prurigo, 778 ; strophulus, 779 ; vesicular erup- 
tions, 779 ; herpes, 779 ; pemphigus, 779 ; duration of the spots, 780 ; 
treatment, 780 ; pustular eruptions, 780 ; ecthyma, 780 ; scaly eruptions, 
780 ; psoriasis, 780 ; value of perchloride of mercury, 781 ; alopecia 
areata, 781 ; treatment, 781. 

CHAPTER II. 
The Erythemata 782 

Erythema simplex, 782 ; its varieties, 782 ; erythema fugax, 782 ; erythema 
papulatum, 782 ; eryth/ma intertrigo, 782 ; the belladonna rash, 783 ; 
diagnosis of simple erythema, 783 ; treatment, 783 ; erythema nodosum, 

783 ; symptoms, 784 ; illustrative case, 784 ; diagnosis, 784 ; treatment, 

784 ; urticaria, 785 ; symptoms, 785 ; diagnosis, 786 ; treatment, 7S6 ; of 
the chronic form, 786 ; roseola, 786 ; symptoms, 787 ; illustrative case, 
787 ; diagnosis, 787 ; treatment, 788. 



Xxiv CONTENTS. 

CHAPTER III. 

PAGE 

Eczema 789 

Causation, 789 ; symptoms, 790 ; varieties, 790 ; eczema simplex, 790 ; eczema 
rubrum, 790 ; eczema capitis, 790 ; impetigo contagiosa, 791 ; eczema tarsi, 
791 ; eczema infantile, 791 ; illustrative case, 791 ; diagnosis, 792 ; treat- 
ment, 792 ; diet, 793 ; local applications, 793 ; treatment of the varieties, 
794 ; baths, 795. 

CHAPTER IV. 

MOLLUSCUM CONTAGIOSUM 790 

Morbid anatomy, 796 ; symptoms, 796 ; diagnosis, 797 ; treatment, 797. 

CHAPTER V. 

The Parasitic Diseases 798 

Scabies, 798 ; the acarus scabiei, 798 ; the furrow, 798 ; symptoms, 798 ; in- 
tense itching, 798 ; various rashes, 799 ; diagnosis, 799 ; treatment, 799 ; 
tinea tonsurans, 799 ; pathology, 799 ; symptoms, 800 ; on the scalp, 800 ; 
on the body (tinea circinata), 800 ; diagnosis, 801 ; treatment, 801 ; in the 
infant, 802 ; in older children, 802 ; various applications, 803 ; tinea 
favosa, 804 ; symptoms, 804 ; diagnosis, 805 ; treatment, 805. 

CHAPTER VI. 
Sclerema 806 

Two diseases often confounded together, 806 ; true sclerema, 806 ; morbid 
anatomy, 806 ; sclerema adiposa, 807 ; symptoms, 807 ; rigidity of skin, 
807 ; low temperature, 807 ; rapid course, 807 ; oedema of new-born in- 
fants, 808 ; symptoms, 808 ; diagnosis between the two diseases, 808 ; 
treatment, 809. 



DISEASE IN CHILDBED. 



INTEODUCTOEY CHAPTEE. 

The difficulties connected with the investigation of disease as it occurs in 
early life may be easily exaggerated. The subject is no doubt a special 
one ; but when the first strangeness has been overcome of dealing with 
patients who cannot describe their sensations, and who show their distress 
by cries and gestures which it requires experience to be able to interpret, 
the chief obstacle to progress has been surmounted. All necessary infor- 
mation as to the onset and early symptoms of the complaint can usually be 
obtained from the mother. Most women are good observers. Affection 
and anxiety increase their watchfulness, and make them fairly accurate re- 
corders of every outward change. The stress laid by them upon particu- 
lar phenomena is not, indeed, always a true measure of the real impor- 
tance of the symptoms ; but it is easy to correct any undue emphasis in 
the narrative by our own judgment and experience. Still, we must guard 
ourselves from being misled by the very fulness of the report : facts may be 
accepted with confidence, but volunteered explanation of these facts must 
on no account be allowed to influence our conclusions. 

When called to a sick child our first care should be to give an attentive 
hearing to the statement of the mother, supplying any gaps in the history 
by suitable questions. Having thus been enlightened as to the previous 
health of the child and the nature of the earliest symptoms, we have next 
to collect what information we can from the appearance and manner of the 
patient. To do this with success we must possess already a certain famil- 
iarity with the ways of infants and young children ; but this is easily ac- 
quired with a little practice. Again, we have so to regulate our own bear- 
ing as not to alarm the child, who is already perhaps in a state of disquiet. 
It has been said that a natural fondness for children is indispensable to 
success in this branch of medicine ; but this is an exaggeration. A quiet, 
genial manner with a pleasant smile and a gentle voice will soon dissipate 
the apprehensions of the patient and gain his confidence. Lastly, we pro- 
ceed to a physical examination of the various organs. This, if done de- 
liberately and without abruptness or hurry, can be effected in most cases 
without much trouble. 

The main difficulty in the diagnosis of disease in early life arises, not 
from the absence of intelligent speech on the part of the patient, nor from 
any uncertainty in the recognition of visible signs of suffering. It springs 
from the perplexity we often feel in referring these symptoms to their true 
origin. Children are not merely little men and women in whose bodies 
1 



2 DISEASE IN CHILDEEN. 

disease manifests itself by exactly the same tokens that are familiar to us 
in the case of the adult. They have special constitutional peculiarities 
which give to disease in early life a character it does not afterwards retain, 
and invest the commonest forms of illness with strange features which 
may be a source of obscurity and confusion. The most striking peculi- 
arity of childhood is a marked excitability of the nervous system — an ex- 
cess of sensitiveness which any deviation from the healthy state brings at 
once into prominence. Consequently, a functional derangement which in 
the adult would give rise merely to slight local symptoms, in the child 
may be accompanied by signs of severe general distress ; and the indica- 
tions of local suffering may be thus overshadowed or completely concealed. 
A common example of this nervous excitability is seen in the disturbance 
which often results from swallowing some indigestible article of food. The 
skin becomes burning hot, the child is in a state of extreme agitation, is 
perhaps convulsed, or lies in a state of stupor from which he can with dif- 
ficulty be roused. In such a case the state of the stomach is apt to be 
overlooked ; for even if the child vomit, which does not always happen, 
the symptom may pass almost unnoticed as one of the consequences of 
the general nervous perturbation. General symptoms of a like character 
may accompany the onset of any acute illness, and their severity bears no 
relation to the importance of the ailment of which they are a consequence. 
As profound a disturbance may be excited by the simplest functional de- 
rangement as by the severest organic malady ; so that to the eye ac- 
customed to the orderly progress of disease in the adult symptoms seem to 
have lost their value and to be calculated rather to mislead than to inform. 
This excitability of the nervous system in early life is a peculiarity which 
must be taken into account in every case of acute illness ; and we must 
endeavour to separate the local symptoms — those which point to mischief 
of a special organ — from others which are merely the expression of the 
general distress. Such local symptoms are the cough, rapid breathing, 
and active nares which point to acute lung disease, the squinting and im- 
mobility of pupils which are so characteristic of cerebral affections, and 
the peculiar jerking movement of the legs which, combined with hardness 
of the abdominal muscles, betray the existence of colicky pain. 

Local symptoms are not, however, to be discovered in every case, and 
even if present cannot always be relied upon to furnish trustworthy indi- 
cations. Owing to the exaggerated impressibility of the nervous system 
a peculiar sympathy exists between the various organs. Consequently, 
symptoms induced by irritation in any part of the body are seldom limited 
to the part actually affected. Signs of distress arise at the same time 
from other and distant organs ; indeed, the organ from which the more defi- 
nite symptoms appear to arise is often not the organ which is the actual 
seat of disease. These deceptive manifestations are most frequently no- 
ticed in the case of the stomach and the brain. In the case of the stomach 
the response excited in this organ by irritation in distant parts of the body 
persists more or less through life. The vomiting of pregnancy and dis- 
ordered uterine function in the female, and of cerebral and renal disease 
in both sexes, is a matter of common observation. In the child, however, 
this sympathy is still more frequently manifested. Vomiting is a common 
symptom at the beginning of most forms of acute illness and in many 
children may be excited by any casual disturbance. The brain again 
shows a marked sympathy with irritation of the more important organs. 
Headache, vertigo, delirium, and stupor are phenomena by no means con- 
fined to cases of intra-cranial suffering. Any serious inflammatory disease 



INTEODUCTOEY CHAPTER. 6 

in the child may be accompanied by such symptoms ; indeed, the ex- 
pression of cerebral sympathy may be so decided as completely to divert 
attention from the part which is really affected. The onset of pneumon in, 
is sometimes complicated by such deceptive symptoms, and the same cause 
for misapprehension may be found in cases of pericarditis and inflammation 
of the peritoneum. So, also, the violent nocturnal delirium — the so-called 
" night terrors " — of children who suffer from worms or other form of gas- 
tro-intestinal derangement must be within the experience of all. 

One of the best illustrations of the excitability of the nervous system 
in early childhood is seen in the case of convulsions. An eclamptic attack 
is a symptom which, in the majority of cases, has a far less grave signifi- 
cance in the young child than it has in the adult. In the latter it is usually 
the evidence of some serious cerebral lesion, and its occurrence excites the 
greatest alarm. In the child, on the contrary, "a fit " is a common ex- 
pression of disturbance in the nervous system. It may be induced in some 
children by a trifling irritant ; and in cases of acute illness is often seen at 
the beginning of the attack, taking the place of the rigor which is so 
familiar a symptom at the onset of the febrile disease in the adult. Con- 
vulsions, however, are not always, in the child, of this innocent character. 
In earlier as in later life, they may occur as a consequence of cerebral dis- 
ease ; but in such a case they are repeated frequently, and are succeeded 
by coma, rigidity, paralysis, and other signs of centric irritation. As a 
rule, single fits, or convulsions unaccompanied by other indication of 
nerve-lesion, occurring in an apparently healthy child, are purely reflex, 
and have no gravity whatever. 

Extreme excitability of the nervous system is, therefore, in early child- 
hood, a natural physiological condition which exercises an important influ- 
ence in disturbing the orderly evolution of symptoms. Into an otherwise 
simple case it introduces a number of redundant features which confuse 
the observer, and may possibly divert his attention from the actual seat of 
suffering. This normal nervous irritability is subject to variations. Thus, 
it may be temporarily intensified by causes which produce sudden depres- 
sion of strength, such as severe acute diarrhoea, or rapid loss of blood. In 
rickets, again, a peculiar feature of the disease is the extraordinary excita- 
bility of the nervous system. As a rule, however, in chronic disease, when 
the interference with nutrition is slow and long-continued, an exactly op- 
posite effect is produced. A young child, especially an infant, if exposed 
for a considerable time to injurious influences so as to suffer both in flesh 
and strength, gradually loses his susceptibility to reflex irritation, and the 
excitability of his nervous system becomes less and less obvious until it 
finally disappears almost entirely. In a child so enfeebled, the system, 
instead of reacting violently against any intercurrent irritation, appears 
almost insensible to nervous impressions. If an attack of acute illness 
occur, we look in vain for the usual signs of general disquiet. Even the 
ordinary symptoms of local suffering may be diminished or suppressed ; 
and were it not for the increase of weakness, and perhaps for a rise of tem- 
perature, the complication might be altogether overlooked. 

This obtuseness of the nervous system is only seen as a consequence of 
long-continued and profound malnutrition. In all such cases, therefore, 
we should watch very narrowly for inflammatory complications, remember- 
ing that such intercurrent diseases may give rise to but few symptoms, and 
may easily escape notice. 

Another peculiarity of early life which attracts attention, is the large 
share taken in infantile disorders by mere disturbance of function, and the 



4 DISEASE IN CHILDREN. 

serious consequences which may arise from derangement as distinguished 
from disease. Infants quickly part with their heat and are easily chilled. 
They are, therefore, peculiarly prone to catarrhal disorders, and these, if 
severe, may produce material interference with the functions of the organ 
affected. No doubt the excitability of the nervous system helps to increase 
the gravity of these derangements. The commotion into which the whole 
system is thrown by the attack, tends to exhaust the patient and greatly to 
enhance the enfeebling influence of the complaint. In infancy, death is 
a not uncommon consequence of these disorders ; and it is for this rea- 
son that post mortem examinations in the infant are so often unsatisfactory. 
It constantly happens that a young child is seized with alarming symptoms 
of illness and quickly dies, yet on opening the body no sufficient morbid 
appearances are discovered to explain the fatal issue of the case. 

Children differ from adults in yet another respect. Diathetic tenden- 
cies are especially active in early life. They exert a remarkable influence 
upon the growing body, shaping the figure, moulding the features, and so 
ordering the structure of organs that any interference with the nutritive 
processes, such as may be produced by ordinary insanitary agencies, is 
followed by widely distributed mischief. Sir William Jenner has drawn 
attention to the number of organs affected at the same time in cases of 
diathetic disease in the child. In a bad case of inherited syphilis, few tis- 
sues or organs escape ; in scrofula the lesions may be almost universal ; 
and in acute tuberculosis all the cavities of the body may be simultane- 
ously affected. Thus, according to the constitutional character of the pa- 
tient and the nature of his ailment, a child may die from mere arrest of 
function, with tissues sound, organs healthy, and no morbid appearances 
left to declare the nature of the complaint ; or may succumb to a profound 
and general disease which visits every part of the body and leaves scarcely 
any organ unaffected. 

It is sometimes said that in a healthy child acute disease naturally tends 
to recovery, but this statement must not be taken without qualification. 
There are some diseases, such as typhoid fever, measles, and perhaps 
croupous pneumonia, which commonly run a milder course in earlier than 
they do in later life ; but there are others, especially acute affections of 
the gastro-intestinal tract, which weigh with peculiar severity upon the 
young. In infancy the patient is so dependent upon a frequent supply of 
nourishment that an abrupt interference with the nutritive processes, such 
as occurs in some forms of bowel complaint, is an event of the utmost 
gravity. Often it is followed by so much exhaustion that the infant rap- 
idly sinks and dies. It is this sudden and complete cutting off of the nu- 
tritive supply which constitutes the chief danger of acute disease in the 
child ; and in early life illness is often serious in exact proportion to 
the degree in which the alimentary canal takes part in the derangement. 
When digestion is not arrested and the system still continues to receive 
nourishment, the child, if in favourable conditions and of healthy constitu- 
tion, will probably recover. The recuperative power of nature is very 
great, especially in the young ; but that it may be free to operate it is es- 
sential that no unfavourable condition be present to impede the iiatur; 1 
course of the illness. Over and above grave implication of the digestive 
organs, other untoward elements may enter into a case, and each of these 
has an influence in weakening the natural tendency to mend. The age is 
a matter of great importance. A new-born infant has but a feeble hold 
upon life and quickly succumbs to an attack of acute illness. Later, the 
child may be burdened with a diathetic taint which has already impaired 






INTRODUCTORY CHAPTER. 5 

his nutrition and lowered his vital energies. Moreover, he may be ham- 
pered by unhealthy surroundings which intensify the weakening influence 
of the original disease, and, indeed, by themselves are often powerful 
enough to prevent recovery. 

Therefore it is only in children of healthy constitution who are placed 
under favourable conditions that illness can be said naturally to tend to re- 
covery, and in them only after the period of earliest infancy has passed by, 
and in cases where, nutrition not being completely arrested, a limited sup- 
ply of nourishment continues to be introduced into the system. 

Sudden death in early childhood, is due, as a rule, to laryngismus, to 
syncope, or to collapse of the lung ; and occasionally it is seen as a conse- 
quence of convulsions. Spasm of the larynx is the common cause of death 
in children who are apparently healthy. Those who die suddenly in the 
course of an acute illness or during convalescence, do so usually from syn- 
cope, or in rarer cases from thrombosis in the pulmonary artery. In 
wasted infants sudden death is more commonly the consequence of pul- 
monary collapse. When a disease is about to end fatally the extremity of 
the danger is shown by a marked alteration in the temperature. In some 
cases we notice a rapid fall, the thermometer registering only 96° or 97° 
in the rectum. In others there is a sudden increase in the bodily heat, 
and the temperature rises quickly to 108° or 109°, The ante-mortem 
cooling is usually noticed in chronic ailments and in bronchitis with col- 
lapse of the lung. The rapid increase iu heat is common in cerebral affec- 
tions and in cases of acute gastro-intestmal derangements. Other un- 
favourable signs are lividity of face, refusal of food, thrush^ rapidity and 
feebleness of the pulse, heaviness and stupor. 

In acute disease when recover}^ takes place, convalescence is usually 
rapid. In an uncomplicated case the strength appears to be recovered al- 
most as quickly as it was lost. Directly the temperature falls, digestion 
and nutrition resume their course and in a surprisingly short time the 
child is well. If convalescence is delayed in such a case it is almost inva- 
riably the consequence of a complication, and it must be remembered that 
this accident is far from uncommon in the child. In all forms of catarrhal 
derangement — a variety of disease to which childhood, as has been said, is 
peculiarly prone — a gastro-intestinal complication may increase the gravity 
of the illness and delay the process of repair. Sometimes the depurative 
functions of the kidneys are imperfectly performed. Sometimes an unab- 
sorbed patch of consolidation in the lung interferes with the return of 
strength. In all cases, therefore, where convalescence from acute disease 
is delayed, or having begun, appears to falter, we should make careful ex- 
amination of the various organs so as to discover the mischief and apply a 
remedy. 

In cases of chronic illness convalescence is usually tardy. The delay, 
no doubt, is partly owing to the fact that this class of disease is common 
in children of a scrofulous habit of body ; and the strumous cachexia is in 
itself a bar to rapid improvement. It is, however, also often due to the 
nature of the illness. In early life, especially in infancy, chronic ailments 
commonly affect the alimentary canal, either primarily or secondarily, and 
the progress of such complaints to recovery is invariably slow. 

In the following pages the term "iufancy" is confined to the two first 
years of life, or to the period which ends with the completion of the first 
dentition ; " early childhood " to the period between the close of the sec- 
ond and the close of the fourth year. The period of childhood ends at 
puberty. This important change occurs at various ages, especially in girls ; 



6 DISEASE IN CHILDREN. 

and some young people remain children both in mind and body to a much 
later date than others. 

In the examination of an infant or young child every care should be 
taken to avoid abruptness or hurry. We must remember that we have to 
do with beings who act not from reason, but from instinct ; that any sud- 
den movement frightens them, a little pressure hurts them, and in either 
case a cry and a struggle bring the examination abruptly to a close. Again, 
young children, as a rule, dislike the sight of a strange face, and if old 
enough to understand the object of the visit, are already prepared to look 
with distrust upon the "doctor." Still, it is a mistake to suppose that 
children always make unmanageable patients. They are no doubt quick 
to take fright ; but it should be the constant care of the practitioner to 
avoid any look or gesture which may arouse their suspicions. If he look, 
speak, and move gently, and do not hurry, most young children will let 
themselves be examined thoroughly without great difficulty. 

On entering the room it is well to accustom them to our presence be- 
fore we even appear to notice them at all. This interval can be usefully 
occupied by questioning the mother as to the onset of the illness, and the 
character of the early symptoms. "We can also take this opportunity of 
inspecting the motions or vomited matters. In searching into the history 
of the case it is especially desirable to obtain some starting-point for our 
investigations. The question " When did the indisposition begin ? " often 
receives only a vague reply ; while an inquiry as to the time which has 
elapsed since the child was last in good health may elicit an account of 
more or less interference with nutrition and indefinite malaise exten ding- 
over a considerable interval. Some tact is often required in obtaining a 
definite account of the beginning and early progress of the illness. It is 
important to avoid suggesting a reply by the character of the question, 
while it is often necessary to be minute in our inquiries in order to stimu- 
late a flagging memory. 

In infants and young children much may be learned from mere inspec- 
tion of the face. It is an advantage in these cases to find the patient 
asleep. We can then study at leisure the colour and general expression of 
the face, the form of the features, the presence or absence of lines or 
wrinkles, and remark if the nares act in respiration or the eyelids close 
incompletely. We can besides notice the attitude of the child, can count 
the pulse and respiration, and can observe their degree of regularity or 
any deviation from the healthy state. Even if the child be awake, many 
of these points can be noticed if we approach quietly and do not speak to 
or offer to touch the patient. Any movements he may make at this time 
in his cot must receive due attention, for they often convey very valuable 
information. 

These points having been noticed, the temperature should be taken. 
In doing this, if the patient be an infant, it is desirable to introduce the 
bulb of the thermometer into the rectum, for at this early age the differ- 
ence between the internal and external temperature of the body is often 
considerable. The child should next be completely stripped of his clothes. 
The state of his skin can then be ascertained, noting the presence or 
absence of eruption ; and a careful examination must be made of the 
abdomen and chest. If the child lose his temper at this time, the quality 
and strength of his cry should be remarked. At the end of the visit the 
gums, mouth, and throat should be inspected, and if any of the child's 
water can be procured, it should be examined for albumen, and its density 
and degree of acidity ascertained. 



INTRODUCTORY CHAPTER. 7 

After this rapid sketch of the method upon which the cliDical examina- 
tion of the infant and young child should be conducted, the chief points to 
which attention must be directed may be considered more in detail. 

In the new-born infant the tint of the face immediately after birth is 
a dull red. The redness, however, soon begins to subside ; in a day or 
two the complexion assumes a slight yellow tint, and then passes into its 
normal coloring. The yellow tint and its diagnosis from infantile jaundice 
are referred to elsewhere (see Jaundice). 

The clear fresh complexion of a healthy baby or young child is familiar 
to every one. A loss of its purity and clearness is one of the hrst indica- 
tions of digestive derangement. The face becomes muddy-looking and the 
upper lip whitish or bluish. Blueness of the upper lip in early life is 
a common sign of laboured digestion. In some children difficult digestion 
is shown by an earthy tint of the face which spreads to the forehead. It 
appears a short time after the meal and may last several hours. In chronic 
bowel complaints the earthy tint is constant. It is common in cases of 
chronic diarrhoea in the infant, and if at the same time there is much 
emaciation, the derangement is likely to prove obstinate. In syphilis the 
prominent parts of the face — the nose, cheeks, chin, and forehead — assume 
a swarthy hue. In lardaceous disease the complexion is peculiarly pallid 
and bloodless ; in rickety children whose spleens are greatly enlarged it 
has a greenish or faint olive cast ; and in cyanosis the face has a char- 
acteristic leaden tint, the conjunctivae are congested, and the eyelids and 
lips thick and purple. Lividity of the skin round the mouth and nose 
with a purple tint of the eyelids is common as a result of deficient aeration 
of the blood. In severe cases the cheeks at the same time have a dull 
white color, and the symptom is an unfavourable one. In the spasmodic 
stage of whooping-cough the face looks swollen as well as livid, the lips 
and eyelids are purple and thick, and the conjunctivae are congested and 
often bloodshot. 

In addition to the actual tint of the face the general expression must 
receive attention. In a healthy babe the physiognomy denotes merely 
sleepy content, and no lines mark the smooth uniform surface. Pain is 
indicated by a contraction of the brows which wrinkles the skin of the fore- 
head. This is especially noticeable if the head is the seat of suffering. If 
the pain be in the abdomen the nose often looks sharp, the nostrils are 
dilated, and the child draws up the corners of the mouth with a peculiar 
expression of distress. In every case of serious disease the face, even in 
repose, has a haggard look, which must not be disregarded. If this be ac- 
companied by a hollow T ness of the cheeks and eyes the result is a ghastly 
expression which cannot escape attention ; but a distressed look may be 
seen in the face although there is no loss of roundness of feature. If this 
be the case, even in the absence of striking symptoms, we may confidently 
predict the onset of serious disease. 

Often an inspection of the face will help us to a knowledge of the part 
of the body affected. Many years ago M. Jadelot pointed out certain lines 
or furrows in the face of an ailing infant w r hich by their position indicate 
the seat of the derangement, thus : 

The occulo-zygomatic line begins at the inner canthus of the eye, passes 
thence downwards and outwards beneath the lower lid and is lost on the 
cheek a little below the projection of the malar bone. This line points to 
disease or derangement of the brain and nervous system. 

The nasal line rises at the upper part of the ala of the nose and passes 
downwards curling round the corner of the mouth. This line is a constant 



8 DISEASE IN CHILDREN. 

feature of abdominal mischief, and is never absent in cases of gastro- 
intestinal derangement. 

The labial line begins at the angle of the mouth and runs outwards to be 
lost in the lower part of the face. This is more shallow than the preced- 
ing. It is a fairly trustworthy sign of disease in the lungs and air- 
passages. 

These lines have a distinct practical value and should be always attended 
to. We should also notice if the eyelids close completery, for imperfect 
closure of the lids during sleep is a common sign of weakness. Moreover, 
it must not be forgotten to ascertain the condition of the pupils and the 
presence or absence of squint. The value of these symptoms, and of 
others connected with the eye, is referred to elsewhere (see page 261). The 
nares must not be forgotten. If they act in respiration the movement is a 
common accompaniment of laboured breathing and often indicates an 
impediment to the respiratory function. It may, however, be present in 
cases w T here there is no conscious dyspnoea, and is sometimes seen in sim- 
ple pyrexia. Even the shape of the features must be attended to. An 
elongated head with square forehead and small lower jaw are characteristic 
of rickets ; a broad flat bridge to the nose, especially if conjoined with 
prominence of the forehead and absence of eyebrows, suggests syphilis ; 
and a big globular head surmounting a small face and little pointed chin 
indicates unmistakably chronic hydrocephalus. 

The attitude of the child as he lies in his cot is not to be overlooked. 
Sometimes it is characteristic. A healthy infant or young child, even if 
lying on his back, inclines to one side and turns his head so as to bring 
the cheek in contact with the pillow. If a baby be found lying motionless 
on his back, with closed eyes and face directed straight upwards to the 
ceiling above him, he is probably the subject of serious disease. This po- 
sition may be seen when the child is unconscious, as from tubercular 
meningitis ; or is profoundly depressed, as in acute inflammatory diar- 
rhoea. If the child he on his side with his head greatly retracted on his 
shoulders, it is a suspicious sign of intracranial disease. If in such a po- 
sition the breathing is audible and hoarse, the case is probably one of 
laryngitis, or there is some impediment to the passage of air through the 
glottis. If the patient be found in his cot resting on his elbows and knees 
with his forehead buried in the pillow, or if he sleep lying on his belly, 
there is no doubt abdominal discomfort. These positions are common 
with rickety children. If the child press his eyelids against the pillow, 
turning partially on his chest, we may suspect intolerance of light. 

Healthy infants and children sleep perfectly quietly. Frequent turn- 
ing of the body or twitching of the muscles generally indicates feverishness 
or digestive derangement. If the child move his head constantly from 
side to side on the pillow, he is probably annoyed with pain in the head 
or ear. Frequent carrying of the hand to the forehead or side of the head 
has usually the same significance. If the child repeatedly flex the thighs 
on the abdomen, and cry violently in sudden paroxysms, he is probably 
suffering from colic. 

The cry of the child is a symptom of considerable importance. It is 
usually elicited by hunger or uneasiness, and from the manner of crying 
we can often gather considerable information. A hungry infant in most 
cases clenches his hands and flexes his limbs — both arms and legs — as he 
utters his complaints ; and will often continue to do so until his desires 
are satisfied. Thirst may also be a cause of crying, and may be suspected 
if the child sucks his lips repeatedly, has a dry mouth, or has been suffer- 



INTRODUCTORY CHAPTER. 9 

ing from purging. If he be tortured by colicky pain, the cry is violent 
and paroxysmal, and is accompanied by uneasy movements of the body 
and jerking of the lower limbs. The belly is also full and hard, and there 
is often a blue tint round the mouth. A shrill scream uttered at intervals, 
the child lying in a drowsy state with closed eyes, is suggestive of tuber- 
cular meningitis. A constant unappeasable screaming is often the conse- 
quence of ear-ache. This painful affection is very common in infants, and 
should be always suspected if the lamentations continue without intermis- 
sion, and the child frequently presses the side of his head against his 
mother's breast. The pain of pleurisy will also cause violent crying. In 
this case pressure upon the sides of the chest, as in lifting the child up, 
causes an evident increase in his suffering. Any alteration in the quality 
of the cry must be noted. It may be hoarse in a young infant from in- 
herited syphilis ; in an older child from laryngitis or enlargement of the 
bronchial glands. 

In a healthy infant a cry is excited at once by anything which causes 
him discomfort or inconvenience ; therefore the absence of crying is a 
syinptoru which should always receive due attention, as it may betoken se- 
rious disease. In inflammatory affections of the lungs, in pulmonary col- 
lapse, and in advanced rickets where the bones are softened, a child will 
bear considerable discomfort without loud complaint, for he has a press- 
ing want for air and dare not hold his breath to cry. So, also, in severe 
diarrhoea or any other illness which causes great reduction of strength, the 
child, on account of his weakness, cries little if at all. Li cases of pro- 
found weakness he will often be noticed to draw up the corners of his 
mouth and wrinkle his brows as if to cry without making any sound. 

In the act of crying tears are copiously secreted after the age of three 
or four months. In serious disease, however, the lachrymal secretion 
often fails. Therefore the absence of tears must be taken to indicate con- 
siderable danger. 

The pulse in the infant can seldom be counted, except during sleep ; 
and even if its rapidity can be ascertained the information thus derived is 
of little value. The rapidity of the pulse in infancy is constantly varying. 
The least movement excites the heart's action, and mental emotions, such 
as fright or anger, almost double the rapidity of the cardiac contractions ; 
so that, according as to whether the infant is awake or asleep, is perfectly 
quiet or has just moved, the pulse may vary frorn between 80 and 90 to 
160 or 180. As a test of physical vigour in babies the pulse is worthless. 
In this respect the fontanelle is of far greater value. In infants under 
twelve months old a sinking of the fontanelle is a sure sign of reduction of 
the strength ; and in touching a child of this age our first care should be to 
pass the ringer over the top of the head and ascertain the condition of this 
part of the skull. In wasted babies the fontanelle often forms a cup- 
shaped depression ; and if the loss of flesh is very rapid, as when a pro- 
fuse drain occurs from the bowels, the cranial bones may often be felt to 
overlap slightly at the sutures. Excess of fluid in the skull-cavity or a hy- 
persemic state of the brain causes bulging and tenseness of the fontanelle. 
Unless very distended the membrane is not motionless. It can be seen to 
move with respiration and to sink appreciably as air is drawn into the 
lungs. 

After the period of infancy has passed, the pulse becomes a far more 
trustworthy guide. During sleep it is fifteen or twenty beats slower than 
during the waking state, and may then be occasionally irregular in rhythm 
or even completely remittent. When the child wakes the pulsations in- 



10 DISEASE IN CHILDREN. 

crease in frequency and usually rise above 100. If at this age the pulse is 
found to fall as low as 60 or 70 in a child who is not asleep, and to intermit 
completely, the sign may be significant of tubercular meningitis. This 
matter is elsewhere referred to (see page 359). 

The respirations should be always counted. In new-born infants their 
number is about 40 or perhaps more in the minute. But the breathing 
soon becomes less rapid, although for a long time the movements are more 
frequent than in the adult, and even after the second year are usually over 
20 in the minute. The normal average is difficult to ascertain, for like 
the pulsations of the heart the breathing varies greatly in rapidity. It is 
rather slower during sleep than when the child is awake, but is apt to be- 
come more hurried from slight causes. More important than the actual 
rapidity of either the breathing or the pulse is the ratio the two bear to 
one another. If the breathing become rapid out of proportion to the 
pulse, the discrepancy should be carefully noted. The normal ratio is 1 
to 8, or 3.5. If this proportion becomes greatly perverted and we find one 
respiratory movement to every two beats of the pulse, we should suspect 
the presence of pneumonia or of pulmonary collapse. The regularity of 
the respiration is also to be noticed. A slight irregularity, especially in 
force, is common in infants ; but if the breathing become markedly irreg- 
ular, the symptom may be an important one. Frequent heavy sighs and 
long pauses, during which the chest is perfectly motionless, are very suspi- 
cious of tubercular meningitis. 

The temperature of the child ought always to be ascertained. It must 
be taken with care. In a healthy infant the temperature of the rectum is 
about 99°, and is fairly constant throughout the day. It rises half a degree 
or so towards the end of digestion, but a marked difference between the 
morning and evening temperature is not noticed in a healthy baby who 
receives proper attention. According to Dr. Squire, if the bodily heat is 
found to vary considerably at different times in the day, the symptom 
should suggest neglect on the part of the nurse or delicacy of constitution 
on the part of the child. If the infant be kept too long without food the 
temperature falls, and will then rise again considerably after the meal. It 
also appears from Dr. Squire's interesting observations upon young babies, 
that the temperature is rather lower during sleep than when the child is 
awake. Even after the age of infancy the temperature is subject to fre- 
quent variations from slight causes ; and in young children mental emotion 
will often induce a degree of fever which may be a source of perplexity. 
In children's hospitals it is a common observation that the bodily heat on 
the evening of admission is high even when the disease is not one usually 
attended with fever. 

On account of the excitability of the nervous system in early life — a 
peculiarity of childhood which has been before referred to — children are 
very subject to what has been called " irritative fever," i.e., to a form of 
pyrexia which results from fretting of the system by various sources of ir- 
ritation. Dentition, as is explained elsewhere, is a frequent promoter of 
this form of febrile excitement, and a pyrexia induced by this means is apt 
to complicate derangements ordinarily non-febrile and be a cause of con- 
fusion. So, also, irritation of the bowels by sc}^bala, indigestible food, or 
parasitic worms, is a common cause of elevation of temperature in the 
young. The febrile movement resulting from the presence of a local irri- 
tant, like other forms of pyrexia in childhood, is generally remittent ; but 
the remissions are not always found at the same period of the twenty-four 
hours. There is not always a fall of temperature in the morning and a rise 



INTRODUCTORY CHAPTER. 11 

at night. One of the peculiarities of this form of febrile disturbance is 
the irregularity of the fever. In a young child a temperature higher in the 
morning than at night should always suggest some reflex cause for the 
pyrexia. 

It is very important not to neglect the use of the thermometer in judg- 
ing of the heat of the body, for not only is the hand very deceptive as a 
guide, but the skin of the patient may appear to be cool although the in- 
ternal temperature is several degrees above the normal level. It is not 
uncommon in cases of inflammatory diarrhoea to find the extremities so 
cold as to require the application of a hot bottle, while a thermometer 
placed in the rectum registers 104° or 105°. Sometimes in young children 
the pyrexia will reach a very high level. At the end of an attack of tuber- 
cular meningitis the temperature is often 109° or 110° ; and the same de- 
gree of febrile heat is occasionally seen in cases of acute gastro-intestinal 
inflammation. In either case the symptom betokens extreme danger ; 
although it must not be concluded that the illness will inevitably prove 
fatal. I have known a baby of a few weeks old recover after its rectal tem- 
perature had risen to the alarming height of 109°. 

Sometimes instead of an elevation the thermometer may show a lower- 
ing of temperature. In infants any reduction in the bodily heat is usually 
a sign of deficient nourishment. In a baby exhausted by chronic vomit- 
ing or purging the temperature in the rectum may be no higher than 97°. 
This is of course an extreme case ; but a lesser depression is often found 
in infants insufficiently nourished, either from watery breast-milk or an 
unsuitable dietary. Again, in convalescence from acute disease the tem- 
perature usually remains for some days or even weeks at a lower level than 
that of health. This phenomenon may be often noticed after typhoid and 
the other eruptive fevers. 

Before leaving the subject of temperature, reference may be made to 
the pyrexia which sometimes attends rapid growth. Several cases have 
come under my notice in which growing girls were exciting great anxiety 
by a persistent evening temperature of over 100°. In one such case, a girl 
of twelve had been kept in bed for five weeks and treated for typhoid 
fever, the girl all the time begging to get up and declaring herself to be 
perfectly well. The patient was brought to me from the country for an 
opinion, as the temperature for six weeks had varied every night between 
99° and 100.6°. I examined the child carefully and could find nowhere any 
sign of disease. She looked healthy and was said to be growing rapidly. 
I accordingly advised that she should be no longer treated as an invalid, 
but should be allowed to get up, be put upon ordinary diet, and be sent 
as much as possible into the open air. This was done, and at the end of 
a fortnight the temperature became normal and did not afterwards rise. 

Having obtained all the information we can without unnecessarily dis- 
turbing the patient, we should next, in the case of an infant or young child, 
have the clothes completely removed so as to be able to make a thorough 
examination of the surface of the body. We can thus notice the condition 
of the skin as to texture and elasticity, and remark the presence or ab- 
sence of eruptions or signs of inflammatory swelling. In a healthy young 
child, the skin is delicate and soft, and of a beautiful pinkish- white tint. If it 
feel dry and have an earthy hue, the change is suspicious of chronic bowel 
complaint. If the skin is wanting in elasticity, we should suspect tubercu- 
losis or renal disease ; and if the kidneys be performing their functions 
imperfectly, the skin may be often seen to lie in wrinkled folds upon the 
abdomen. Dryness, with a dingy hue of the skin, is also common in some 



12 DISEASE IN CHILDEEN. 

forms of hepatic disease, and occasionally in chronic tubercular peritonitis. 
At this part of the examination, any sign of tenderness either general or 
local should receive attention. The sharper cry of pain is usually to be 
readily distinguished from the cry of irritability or anger. In rickets 
there is general tenderness which makes all pressure painful. In pleurisy 
pressure upon the sides of the chest, as in lifting the child up, is a cause 
of acute suffering. Sometimes signs of local tenderness can be discovered, 
such as may accompany the formation of matter beneath the surface ; or 
again, slight tenderness of a joint may be the only indication of rheuma- 
tism in the child. 

The attention should next be directed to the respiratory movements. 
In healthy young children respiration is chiefly diaphragmatic. Forcible 
movement of the thoracic walls is a sign of laboured breathing, and is a 
constant symptom of broncho-pneumonia. Great recession of the lower 
parts of the chest suggests an impediment to the entrance of air into the 
lungs. If at each inspiration there is great recession of the epigastrium, 
the lower part of the sternum being forced inwards so as to produce a 
deep hollow in the centre of the body, the obstruction is probably in the 
throat or larynx. Such a depression is seen in the case of retro-pharyn- 
geal abscess, in stridulous laryngitis, and diphtheritic croup. If the chest 
fall in laterally so as to produce a deep groove, running downwards and 
outwards at each side of the chest, while at the same time a horizontal fur- 
row form at the junction of the chest with the abdomen, the impediment 
is due to softening of the ribs. This is characteristic of rickets. 
Sometimes in children who suffer from enlarged tonsils a cup-shaped de- 
pression is seen at the lower part of the sternum. It is right, however, to 
say that this deformity is not confined to children with enlarged tonsils. 
I have seen it well marked in patients in whom the pharynx was perfectly 
normal, and in whom no impediment appeared to exist to the entrance of 
air into the lungs. If the chest move more freely on one side than on the 
other, we should suspect grave mischief on the side on which the move- 
ment is hampered. Still, in the child serious disease of the chest may be 
present without our being able to detect any such difference. Even in 
cases of copious pleuritic effusion, no impairment of movement in the in- 
tercostal spaces of the affected side may be visible. Marked contraction 
of one side of the thorax with curving of the spine is suggestive of a late 
stage of pleurisy, or of an indurated lung. 

In the healthy child the abdomen moves freely in respiration. If it be 
motionless, therefore, an inflammatory lesion of the belly should be sus- 
pected. If the superficial veins of the abdomen are unnaturally visible, 
the symptom is suggestive of some impediment of the abdominal circula- 
tion, such as would be produced by enlarged mesenteric glands or hepatic 
disease. In young children the belly is always disproportionately large. 
Its size is due to shallowness of the pelvis, to flatness of the diaphragm, and 
to laxness of the muscular walls, which yield before the pressure of the 
flatus in the bowels. In some healthy infants the abdomen is much larger 
than it is in others. The difference is probably due in most cases to an 
exaggerated amount of flatus formed in the bowels during digestion. The 
size of the belly from this cause sometimes alarms parents ; and it is not 
uncommon to be consulted with regard to this point in the case of young 
children who are in every respect perfectly healthy. Often, however, the 
enlargement is due to increase in size of the liver and spleen, to the pres- 
ence of a growth, or to accumulation of fluid in the peritoneum. The size 
of the liver and spleen may be ascertained by placing the hand flat upon 



INTRODUCTORY CHAPTER. 13 

the abdomen, the fingers pointing to the chest, and pressing gently with 
the finger tips. In this way with a little practice the edges of these organs 
can readily be felt. At the same time, if the child be not crying, we can 
ascertain the degree of tension of the abdominal wall and the presence or 
absence of fluctuation. Abnormal tension of the parietes, especially if it 
be more marked on one side than on the other, is suggestive of peritonitis 
or ulceration of the bowels. For the means of diagnosis of the several 
conditions which give rise to abdominal enlargement the reader is referred 
to the chapters treating of these subjects. 

If, instead of being distended, the belly is markedly retracted we have 
reason to suspect the presence of tubercular meningitis. To examine the 
abdominal organs at all satisfactorily the child must lie on his back with 
his head and shoulders raised by a pillow. The mother or nurse should 
sit upon the bed by his side, and the practitioner should take care that the 
hand he applies to the belly is warm and does not press too abruptly so as 
to give pain. This part of the examination is usually submitted to without 
ojyposition if the child be humoured and cheerfully talked to. 

Even an examination of the chest can generally be undertaken without 
fear of failure. Infants, as a rule, seldom give much trouble ; and if there 
is any serious disease present in the lung, they are too much occupied by 
the needs of respiration to spare time to cry. In early childhood there is 
more reason to fear opposition, but with patience the examination can usu- 
ally be carried to a successful issue. A stethoscope is seldom objected to 
if it be first placed in the child's hand and called a trumpet. For further 
remarks upon this subject and the peculiarities of the plrysical signs in 
childhood the reader is referred to the special chapter on examination of 
the chest in children. 

Inspection of the mouth and throat should be always deferred to the 
end of the visit, as this part of the examination invariably produces every 
manifestation of "displeasure. An infant will often protrude his tongue 
when gentle pressure is made upon his chin, and a finger can be usually 
passed over his gums without sign of opposition ; but to look at the throat 
we are forced to depress the tongue. If any symptoms are noticed requir- 
ing the operation, every precaution should be taken to render it successful. 
The nurse sitting in a low chair facing the window or a good lamp, holds 
the child straight upon her lap with his back resting against her chest. 
She then with her arm thrown round his body prevents the patient from 
changing his position or raising his hands to his mouth. At the same time 
an attendant standing behind her with a hand on each side of the child's 
face holds his head in a convenient position. Matters being thus arranged 
it is the practitioner's own fault if he do not obtain a good view of the 
fauces. Firmness is absolutely necessary at this point. Any other plan is 
equally annoying to the patient, and is almost certain to end in failure. 
Before inspecting the throat, the sides of the neck should be examined for 
evidence of swollen cervical glands. 

In some cases it is important to ascertain if the child takes the breast, 
sucks the bottle, or drinks from a cup with ease. In infantile tetanus the 
mere fact that the patient is able to swallow enables us to speak less un- 
favourably of his chances of recovery. In cases, too, of apparent stupor, if 
the child still continue to take his food the sign is a favourable one. If a 
child be suffering from acute lung disease, he sucks by short snatches, 
stopping at frequent intervals to draw his breath. A syphilitic child with 
occlusion of the nares sucks with great difficulty, as his nose is useless for 
respiratory purposes and all air has to pass through his mouth. An infant 



14 DISEASE IN CHILDREN. 

with bad thrush has much pain in drawing the milk from soreness of his 
mouth and tongue, and may refuse his bottle altogether. If the throat be 
sore the child swallows noisily, and often relinquishes the nipple to cough. 

Lastly, the practitioner should be careful to inspect the vomited mat- 
ters and discharges from the bowels, as the description of their appear- 
ance given by the best nurses is rarely to be trusted. The varieties of 
loose stool are elsewhere considered. Food vomited sour from the stom-^ 
ach indicates a catarrhal state of the gastric mucous membrane. Much* 
mucus mixed with the ejected matters is also a sign of the same condition. 
Vomiting is not, however, always a symptom of distress. An infant who 
has swallowed too large a quantity of milk, or has taken his bottle too 
hastily, will often eject a part of the meal ; but in such a case there is 
nothing offensive about the matters thrown up and the child himself shows 
no sign of distress. 

In the treatment of disease in early life the actual administration of 
physic is of less importance than a careful regulation of the diet and at- 
tentive nursing. It is the duty of the practitioner to see that no impedi- 
ment is thrown in the way of the proper working of the various functions ; 
that the stomach is supplied with food it can digest, that the skin, the kid- 
neys, and the bowels are encouraged to carry on their duties as emuncto- 
ries, that the air of the room is kept pure and frequently renewed, and is 
moreover maintained at a suitable temperature. 

Febrile attacks are very common in childhood, and if the temperature 
is high (i.e., above 100°), which it may be from very slight and transient 
causes, the child should be confined to his bed and kept there as long as 
the pyrexia continues. In all forms of fever the child should occupy a 
large, well-ventilated room. This should be kept at the temperature as 
nearly as possible of 65°, and every care should be taken to maintain the 
air of the room fresh and pure. Still, no draught must be allowed. If 
the window is open the patient must be scrupulously protected from all 
currents of air. No discharges from the body, soiled linen, dirty plates or 
dishes should be allowed to remain in the sick-room a moment longer than 
is necessary ; and in the case of the infectious fevers the excreta must be 
disinfected at once, and the soiled sheets and other linen steeped after re- 
moval in a tub of water containing carbolic acid or other disinfectant. 

All noise and bustle must be prohibited ; and few persons must be al- 
lowed at the same time in the room. If the child require amusement, he 
must be allowed only such unexciting diversions as books, pictures, and 
quiet games can afford. His food should be of a light, unstimulating kind, 
such as thin broth, milk, light puddings, and jelly. His thirst may be 
assuaged at frequent intervals, care being taken, however, that only small 
quantities of fluid are allowed on each occasion. Too large quantities of 
liquid distend the stomach, impair the digestion, and help to promote 
diarrhoea. This is a fact of some moment in the treatment of diseases 
where purging is a common symptom, as measles and typhoid fever. It 
is advisable to make use of a small glass holding about two ounces, for the 
child will be usually satisfied if allowed to drain this to the bottom. As 
the patient grows weaker and requires more decided support, he may be 
given pounded underdone mutton, strong beef-essence, yolks of egg, and, 
if stimulants are required, the brandy-and-egg mixtuie of the British Phar- 
macopoeia. 

In cases where deglutition is difficult or impossible, as in infantile teta- 
nus or the paralysis which follows diphtheria, and in all cases where from 
wilfulness or incapacity an adequate supply of food is not taken, it may 



INTRODUCTORY CHAPTER. 15 

be necessary to feed the child through a tube introduced into the stomach. 
This operation is best performed by passing an elastic catheter through 
the nose and down the gullet. The instrument is more conveniently in- 
troduced through the nose than through the mouth. Less opposition is 
aroused by this method, and little or no irritation appears to be set up in 
the nasal passages. The tube l properly oiled must be directed along the 
floor of the nasal cavity into the pharynx, and can be then readily pushed 
down the gullet into the stomach. If it catch against the top of the lar- 
ynx, a spasmodic cough is excited. The instrument must be then with- 
drawn slightly and again pushed forwards. There is little difficulty about 
the operation if the child's head be directed well backwards. By this 
means liquid food can be administered regularly ; and in certain diseases 
— especially infantile tetanus, where nourishment is urgently needed and 
is indispensable to success in the treatment — feeding through the nose 
becomes a valuable addition to our resources. 

If the power of swallowing be unimpaired, a simpler method may be 
adopted. In such a case it is only necessary to carry the food into the 
fauces. If other means are not at hand, fluid nourishment may be poured 
directly into the nostril as the child lies in his cot. The liquid at once 
gravitates to the back of the throat and is swallowed as it reaches the 
pharynx. If preferred, the fluid may be injected through a short caout- 
chouc tube passed through the nose to the upper part of the gullet. In 
most of these cases, however, the simple and ingenious method devised by 
Mr, Scott Battams, 2 and introduced by him into the East London Chil- 
dren's Hospital, may be resorted to. In the case of weakly or collapsed 
infants this method is invaluable ; but children of all ages, if prostrated 
by illness, can take nourishment more conveniently by this means than by 
any other. The apparatus is of the simplest kind, and consists merely of 
an ordinary glass syringe with a piece of India-rubber tubing, four inches 
long, slipped over the nozzle. The syringe is filled in the ordinary way 
by drawing up fluid through the tubing. The tube is then passed between 
the child's lips towards the back of the tongue and the contents of the 
syringe are slowly discharged into the mouth. 

These different methods of feeding are all useful. The stomach-tube 
passed through the nose should be employed in all cases where deglutition 
is impaired, from whatever cause — either from inflammatory conditions of 
the throat, from loss of excitability of the pharynx owing to cerebral dis- 
ease or narcotic poisoning, or from paralysis, as after diphtheria. The 
syringe-feeder just described may be used in cases of great weakness and 
prostration, and in all cases where the power of swallowing is not inter- 
fered with. 

The question of reducing temperature when this rises to a dangerous 
height is an important one. Children often bear a high temperature well, 
and it is not always easy to say what degree of heat constitutes hyperpyrexia 
in a child. When the fever is due to a septic cause it is perhaps less well 
borne than when it is the consequence merely of a local inflammation. In 
any case if the temperature rise above 106°, or if the. patient seem to be 
distressed by a less degree of heat, it is advisable to sponge the surface of 
the body with tepid water. If the fever be not reduced by this means, the 

] The best tube to use is a vulcanised india-rubber catheter sufficiently stiff not to 
kink. A jS"o. 7 is the most useful size. 

* Mr. Battam's paper on the Forced Feeding of Children, in the Lancet of June 
16 and 23, 1883, in which the various methods of feeding are described, is full of in- 
terest and instruction. 



16 DISEASE IN CHILDREN. 

child should be placed in a bath of the temperature of 75°, and be kept 
there until the pyrexia undergoes a sensible diminution. Usually spong- 
ing the surface will reduce the bodily heat by several degrees, to the im- 
mediate relief of the patient. In cases of inflammatory diarrhoea, even in 
babies of a few months old, the temperature often rises to 109° or 110°, 
and the child passes into a state of profound depression. When this hap- 
pens death is inevitable unless the pyrexia can be quickly reduced ; and 
tepid bathing is often successful in greatly retarding if it do not actually 
prevent a fatal issue to the illness. 

In all forms of fever the comfort of the patient is greatly promoted by 
the use of two cots — one for the day, the other for the night. In cases of 
pericarditis with copious effusion, in the later period of typhoid fever, 
and in other instances where the debility is extreme or the action of the 
heart hampered and feeble, the change from one cot to the other must be 
made with every precaution to spare the child all spontaneous movement, 
and to keep him in a recumbent posture. 

In the treatment of disease in early life the remedies at our command 
are the same as are useful for similar conditions in the adult. On account 
however, of the impressible nervous system in the young subject external 
applications are of greater importance in childhood than they become in 
after years. Amongst the remedies of the greatest value baths form a 
class of no little importance. According to the temperature of the water 
employed the bath becomes a sedative, a stimulant, or a tonic, as may be 
required ; and in these different shapes is often resorted to with great ad- 
vantage. The usefulness of tepid bathing in reducing fever has already 
been referred to. 

The warm bath (80° to 85° Fah.) is very useful in cases of convulsions 
or great irritability of the nervous system, shown by agitation, restlessness, 
spasm or disturbed sleep. It calms the excitement, allays spasm, pro- 
motes the action of the skin, and induces sleep. On account of its diapho- 
retic effect warm bathing is of great service in cases of Bright 's disease. In 
infants the warm bath has a sensible influence in promoting the action of the 
bowels, and in cases of constipation is often a valuable addition to purga- 
tive medicines. The child should remain from ten to twenty minutes in 
the warm water. 

The hot bath (95° to 100° Fah.) is of great value as a stimulant where 
there is sudden and severe prostration, such as occurs in cases of profuse 
diarrhoea, urgent vomiting, shock, or other cause which induces a temporary 
depression of the vital energies. When employed in this way as a stimu- 
lant the child must not remain too long in the water or the stimulant effect 
will pass off and be succeeded by depression. For "an infant three, and 
for an older child five minutes will be sufficient immersion. The patient 
can then be removed, wiped rapidly dry, and laid between blankets with a 
hot bottle to his feet. This bath may be made more stimulating by the 
addition of mustard. Flour of mustard, in the proportion of one ounce 
to each gallon of water, is mixed up with a little warm water into a thin 
paste and placed in a piece of muslin. This is squeezed in the hot water 
until the latter becomes strongly sinapised. So prepared, the mustard 
bath is an important remedy in cases of prostration and collapse. The 
child should be held in the bath until the arms of the attendant supporting 
him begin to tingle. 

The cold douche is a tonic of the utmost value. It must, however, be 
employed with discretion, for the patient if weakly seldom obtains a proper 
reaction unless special precautions be taken. If the child look blue or 



INTRODUCTORY CHAPTER. 17 

feel chilly after tlie bath, the shock to the system has been too violent. 
For a weakly child the cold douche should always be given in the follow- 
ing way : On rising from his bed the child is thoroughly shampooed all 
over the body, using steady frictions especially to the back and loins. 
His skin being thus stimulated and pre}Dared to resist the shock of the 
cold water, the patient is made to sit in a few inches of water as hot as he 
can conveniently bear it, and then immediately a pitcher of cold water (55° 
to 60°) is emptied over his shoulders. He is then at once removed, and 
well rubbed with a rough towel to assist reaction. In winter the bath 
should be placed before the fire, and every care should be taken to make 
the process a rapid one. The shampooing will occupy from ten to fifteen 
minutes, but the douche should be over in as many seconds. It is well to 
allow the child a drink of milk or a biscuit before beginning the process ; 
and when dried the child may return to his bed for a short time if thought 
desirable ; but after one or two repetitions of the bath this precaution will 
be unnecessary. So employed, the bath must be regarded purely as a 
therapeutic agent, and not as a cleansing process. The body may be washed 
in the ordinary way at night before the child is put to bed. 

The cold douche is of great service in all cases of weakness, whether 
this be due to acute or chronic illness, and is only inadmissible if the lungs 
are actively diseased or there is fever. It is especially useful in cases of 
long-standing derangement and in the scrofulous cachexia, and may be 
recommended without hesitation for children of very fragile appearance. 
In addition to its tonic effect the bath has another valuable quality in that 
it strengthens the resisting power of the body against changes of tempera- 
ture, and lessens the susceptibility to cold. 

The hot and mustard baths may be considered in the light of counter- 
irritants, which act through the surface generally and produce a powerful 
stimulating effect upon the flagging nervous system. A similar means of 
rousing the vital energies consists in the employment of stimulating lini- 
ments. Thus, in cases of atelectasis, energetic frictions with a strong irritat- 
ing application will often enable the child to expand the collapsed portion 
of lung, and thus save him from immediate danger. In many varieties of 
local disease, counter-irritants are of extreme service. They may be used 
in the form of blisters, mustard poultices, and painting with the tincture 
or liniment of iodine. The kind of application best suited to each particu- 
lar case will be described in the proper place. It may be here stated, how- 
ever, that blisters must be used to children, especially to young infants, 
with great caution ; and Bretonneau recommends that in every case a thin 
layer of oiled paper should be interposed between the vesicating surface 
and the skin. A blister applied too long leads, as M. Archainbault has 
pointed out, to a sore equivalent to a burn of the third degree, and heals 
very slowly. Caution in the application of the more powerful counter- 
irritants is especially to be observed when the patient is very young, or is 
the subject of defective nutrition or of chronic disease. In such cases ob- 
stinate ulceration may be set up, or gangrene of the skin may be induced, 
not to mention the exhausting effect upon a weakly patient of the pain 
caused by the application of the irritant, and the effusion of a highly albu- 
minous fluid. If diphtheria be epidemic in the neighbourhood, blisters 
should never be employed, as the resulting sore may become covered with 
the diphtheritic exudation. For a young child a blister should be of small 
size and ought quickly to be removed. Under twelve months of age can- 
tharidine applications should rarely be resorted to. If used during the 
second year, the blister may remain in contact with the skin for an hour 
2 



18 DISEASE IN CHILDREN. 

and a half. For each additional year of life a further half hour may be 
added to the length of time the application may be employed ; so that for 
a child of four years of age the blister may remain two hours and a half ; 
for a child of five, three hours. If vesication has not been produced when 
the irritant is removed, a warm bread-and-water poultice will soon cause 
it to appear. The fluid can then be let out and cotton wadding applied. 
No other dressing will be required. 

Amongst internal remedies alcoholic stimulants take a high place. Chil- 
dren reduced by severe illness respond well to the action of alcohol, and a 
few timely doses of this medicine have often, in a doubtful case, turned 
the scale in favour of recovery. So, also, weakly children with poor appe- 
tites and feeble digestions often benefit greatly by an allowance of wane 
with their principal meal. Stimulants may be prescribed for the youngest 
infants, and in cases of great weakness may be repeated at frequent inter- 
vals. When the patient is very young and requires energetic stimulation, 
a small quantity of wine or brandy often repeated is to be preferred to a 
larger quantity given at more distant intervals. The remedy should not 
be continued too long. It must be remembered that a stimulant is not a 
tonic. It is given for an immediate purpose, and should be withdrawn 
or greatly reduced in quantity when the object has been attained. 

Tonics, such as quinine, iron, the mineral acids, and vegetable bitters, 
are also of great value in the treatment of disease in the child. But they 
require to be given with judgment, and must not be administered indis- 
criminately because the patients look weak and pale. A feeble-looking, 
pallid child, is not always to be benefited by iron and other tonics. Such 
a condition is often dependent upon a chronic form of dyspepsia, the result 
of repeated catairhs of the stomach. In such cases a proper selection of 
food, and alkalies given to diminish the secretion of mucus and neutralise 
acidity, will soon produce a marked improvement in cases where tonics 
have been given without good result. It is only when local derangement 
has been remedied that the tonic becomes useful. The same remarks 
apply to cod-liver oil. This valuable remedy is inappropriate so long as 
any digestive derangement remains uncorrected. When the alimentary 
canal has been brought into a healthy state, the oil is of enormous service, 
and may be given in suitable doses to the youngest infants. It must be 
remembered, however, that the power of digesting fats in early life is not 
great. Under twelve months of age ten drops will be a sufficient quantity 
to be given on each occasion ; and if any oil is noticed undigested in the 
stools, even this small quantity must be reduced. 

In cases where, although nourishment is urgently required, oil cannot 
be digested, the remedy may be rubbed into the skin. The external appli- 
cation of oil is of service in all cases of chronic weakness and wasting. It 
is useful not only as a means of introducing nourishment, but also as an 
agent in promoting the action of the skin, which in most forms of chronic 
derangement is apt to become inactive and dry. The application should 
be made at night. Any oil is useful for the purpose, and it is not indis- 
pensable that cod-liver oil be employed. The oil should be w^armed and 
then applied to the whole body with a piece of fine sponge. At the same 
time if there is any special weakness in the back or elsewhere, vigorous 
friction with the oil may be used to the part it is desired to strengthen. 
Afterwards the child should be put to bed in a flannel night-dress. 

In the administration of drugs to young subjects, we must remember 
that the dose is not always to be calculated according to the age of the 
child, but that children have a curious tolerance for some remedies and as 



INTRODUCTORY CHAPTEE. 19 

curious a susceptibility to others. Opium, it is well known, should be 
given with caution. The remedy is, however, of extreme value, and if care 
be taken to begin with only a small quantity, and to postpone a second 
dose until the effect of the first has been ascertained, no ill effects can pos- 
sibly be produced by the narcotic. Thus, for a child of twelve months old 
suffering from purging, if one drop of laudanum has not produced drowsi- 
ness, a second may be given in six hours' time ; and the remedy will be well 
borne three times a day. 

Belladonna can be taken by most children in large quantities. Some- 
times the characteristic rash is produced by a small dose, but a much 
larger quantity will be required to dilate the pupil, and a further consid- 
erable increase before we can produce dryness of the throat or other 
physiological effect of the drug. It is often necessary to push the dose so 
as to produce dilatation of the pupil. Many cases of nocturnal inconti- 
nence of urine show no sign of yielding until some symptoms are pro- 
duced indicating that the system is responding to the action of the remedy. 
A child of twelve months old will usually take fifteen, twenty, or more drops 
of the tincture of belladonna three times a day ; and often we can push the 
dose at this age far beyond this limit. 

Besides belladonna children bear well quinine, digitalis, arsenic, lobelia, 
and many other remedies. Mercury rarely salivates a child, but has often 
a powerful effect in deteriorating the quality of the blood. A child is 
usually left excessively pale at the end of a course of this drug. 

On account of the frequency of digestive disturbances and the tendency 
to acidity in early life, alkalies form a very valuable class of remedies. A 
dose of bicarbonate of soda or potash neutralises acidity, checks hyper- 
secretion of mucus, and if given with a few drops of spirits of chloroform 
and an aromatic, stops fermentation, dispels flatus, and reduces spasm. In 
all varieties of dyspepsia in the child, and in many forms of looseness of 
the bowels, this combination is of the utmost value. 

One word may be said with reference to the abuse of aperient medi- 
cines which is so common in the nursery. Delicate children have often 
died from the effects of a drastic purge, and many a case of typhoid fever 
has received a fatal impulse by this means. An aperient is the common 
domestic remedy — the corrective to be administered at once upon the 
slightest appearance of illness ; and prescribing chemists invariably recom- 
mend it as an antidote for every ill. But constipation is only one of many 
causes of malaise, and to irritate the bowels unnecessarily with a strong 
purgative powder may do serious injury to a weakly child. 



art 1. 
FECTIOUS DISEASES. 



CHAPTER I. 

MEASLES. 



Measles (rubeola or morbili) is one of the commonest infectious fevers to 
which children are liable ; and few persons arrive at adult years without 
having suffered from an attack. It affects children of all ages, and is far 
from uncommon in infants. Scattered cases of measles may be found 
almost at any time in large towns, but at certain periods of the year the 
complaint becomes epidemic. These epidemics vary curiously in severity 
and in the predominance of particular symptoms. One may be signalized by 
a high percentage of mortality. In another vomiting may be a prominent 
and distressing feature. In a third the catarrhal phenomena may be 
unusually slight ; or again, they may be severe out of all proportion to the 
intensity of the rash. When fatal, measles is so generally through its com- 
plications. It rarely kills by the intensity of the general disease. Still, in 
some cases we meet with epidemics in which the disease tends to assume 
an asthenic type. In these the mortality is high. The fatal cases are 
marked by early and extreme prostration. The patient seems overwhelmed 
by the violence of the attack, and dies before any complication has had 
time to manifest itself. As a rule, one attack protects against a second, but 
cases where the disease has occurred two and even three times are not un- 
common. 

The contagious principle of measles is apparently communicated by 
means of the breath. It is said to be volatile, and to be capable of adher- 
ing to clothing. According to Meyer, it is easily removed, as the mere 
airing of clothes is sufficient to disinfect them. Messrs. Braidwood and 
Vacher have examined the expired air of measles patients by making them 
breathe through glass tubes coated in the interior with glycerine. On 
examination afterwards with the microscope, the glycerine showed in every 
case numerous sparkling colourless bodies, some spherical, others more 
elongated with sharpened ends. They were most abundant* during the 
first and second days of the eruption. As a negative test, the breath from 
healthy children, and children suffering from scarlatina and typhus, was also 
examined, but without any result. 



22 DISEASE IN CHILDREN. 

The infection of measles begins at the very beginning of the catarrhal 
stage, and lasts for some time after the rash has faded. Dr. Squire is of 
opinion that three weeks ought to elapse before the patient can be con- 
sidered free from all chance of communicating the disease. 

Morbid Anatomy. — The post-mortem appearances in cases of death from 
this complaint are those of the complication to which the fatal termination 
is owing. In cases where the child has died early from the severity of the 
disease, little is found except that the blood is dark coloured, deficient in* 
fibrine, and coagulates imperfectly. There is also hypostatic congestion of 
the lungs and hyperemia of the mucous membranes and organs generally, 
with extravasation into their substance. The spleen and lymphatic glands 
are often swollen. Sections of the skin made on the sixth day of the erup- 
tion were examined by Messrs. Braidwood and Vacher. There was swelling 
of the corium, and thickening of the rete Malpighii from great proliferation 
of cells, which extended along the hair and sweat-ducts into the glands. 
Sparkling, colourless, spheroidal, and elongated bodies, similar to those 
discovered in the breath, were found in the portion of the true skin lying 
next to the rete, in the lungs, and in the liver. In all these situations these 
bodies were mixed with other bodies, spindle-shaped, staff-shaped, and 
canoe-shaped. They appeared to be albuminoid in character. 

Symptoms. — The incubation period of measles is ten or twelve days. 
The complaint then begins with the signs of catarrh. The patient is 
thought to have a cold : he sneezes, coughs, and his eyes look watery and 
red. "With this there is fever ; often headache ; the appetite is poor ; and 
the child generally feels ill and is languid. The catarrhal symptoms in- 
crease ; the nose may bleed ; there is some soreness of throat ; and the 
patient is often hoarse, and complains of soreness in the chest. If the 
fever is high, the child may wander at night and be very restless. Some- 
times the attack is ushered in by a convulsive fit, and occasionally the 
convulsions recur later on, either before the rash has appeared or after- 
wards. The skin is generally moist, although the temperature rises to 102° 
or 103°, or even higher. In a case Avhich came under my own notice at 
this stage, a boy was seized with diarrhoea on July 10th. His temperature 
on that evening was 102°. The next morning it was 103°, but the bowels 
acted five times in the course of the day, and in the evening it had fallen to 
101.4°. His pulse at that time was 160, and his respirations were 48. On 
the evening of the 12th the temperature was 102°, and on the morning of 
the 13th, when the rash appeared, the mercury marked 103° ; pulse, 124 ; 
respirations, 48. Although pyrexia is the rule during the pre-eruptive stage, 
in exceptional cases the temperature may be normal. I have known this 
to be the case in two instances. In each of these young children the 
bodily heat, both morning and evening, for the four days before the appear- 
ance of the rash was between 98° and 99° ; and when the eruption began 
the temperature only rose to 101°. The rash was typical in character, 
and all the catarrhal symptoms were present. 

The digestive organs are usually deranged, partly on account of the 
fever ; partly on account of the mucous membrane of the stomach sympa- 
thizing with the general derangement. The tongue is thickly furred ; 
there is often vomiting ; and the bowels may be relaxed. 

The characteristic eruption appears as a rule on the fourth day, having 
been preceded by three clear days of catarrh and fever. In rare cases it is 
seen on the third day ; or, again, it may be delayed until the fifth, or even 
longer ; but these are exceptions. There is seldom any appreciable sub- 
sidence of the fever on the appearance of the rash. Indeed, the opposite 



MEASLES— SYMPTOMS. 23 

is usually the case. Both the fever and the catarrhal symptoms seem to 
be intensified when the rash comes out ; and if diarrhoea have not been 
present before, the bowels generally become loose. 

The eruption is first seen about the chin, the temples, and the fore- 
head, as slightly elevated spots of a yellowish red colour, which disappear 
under pressure. Small at first, they soon reach one and a half or two 
lines in diameter, and have irregular edges. From the face the rash soon 
spreads to the trunk and limbs, and in twenty-four hours is generally 
found to cover the whole surface of the body and extremities. As it 
spreads, the borders of neighbouring spots unite so as to form crescentic 
patches. Between these the skin is of normal colour, unless the eruption 
be very profuse, in which case, as we often see on the face, the junction of 
the closely set spots may produce a uniform blush over a considerable 
extent of surface. 

As the rash becomes more completely developed, its colour grows of a 
deeper red ; and if the skin be very moist, vesicles with an inflamed base 
may be seen scattered over the surface. A child with the eruption fully 
out and the catarrhal symptoms well marked, presents a very character- 
istic appearance. His face is somewhat swollen, so that the features appear 
thick and coarse. A dull red flush occupies each cheek ; and the forehead, 
mouth, and chin are speckled over with the crescentic patches. The eyes 
are red ; the eyelids congested ; and the upper lip is excoriated by the 
copious flow of thin mucus from the nose. Often crusts of dried blood 
are seen about the nostrils, for epistaxis is a very common symptom. The 
rash remains at its height for about twenty-four or forty-eight hours, and 
then begins to fade. The colour changes again to a yellowish red, and in 
a day or two has disappeared, leaving nothing on the skin but a faint red- 
dish stain, which may last for a few days longer before the normal colour 
of the integument is completely restored. 

There are varieties in the rash. Sometimes the spots when they first 
appear are hard, scattered, and prominent. These are the cases which are 
often mistaken for variola. Sometimes the eruption does not completely 
disappear under pressure, and we then often find little points of extrava- 
sation from rupture of small capillaries in the skin. This occurs in cases 
where there is great hyperemia of the cutaneous tissue. It is of no bad 
augury. A further degree of the same phenomenon is sometimes seen in 
which the eruption grows darker and darker until it has acquired a deep 
purple tint. This is also the consequence of rupture of distended cutane- 
ous capillaries. Such a rash does not disappear with pressure, and re- 
mains visible for a much longer time than an"' ordinary eruption, f ading very 
slowly. 

The fever and catarrh remain at their height until the rash begins to 
facie. The severity of the catarrhal symptoms varies very much in differ- 
ent epidemics and with different patients. Sometimes all the mucous 
membranes seem to suffer : the throat is sore ; the ej^es are inflamed ; 
there is deafness from closure of the Eustachian tube, and the inflammation 
may even spread to the middle ear ; vomiting may be distressing, and 
purging severe ; a mild laryngitis may become intensified and be accom- 
panied by spasm (stridulous laryngitis). All these symptoms are usually 
greatly relieved when the eruption begins to disappear ; and if there be 
no complication sufficiently serious to maintain the pyrexia, the tempera- 
ture falls at once to nearly its natural level, and the pulse loses much of 
its frequency. 

The disappearance of the rash is followed by a fine desquamation of 



24 DISEASE IN CHILDEEN. 

the skin. The peeling differs much from the shedding of the skin which 
is such a marked symptom in scarlatina. The epithelium falls in fine bran- 
like scales which are often almost invisible to the naked eye, so that this 
stage not unfrequently passes quite unnoticed by the attendants. 

In an uncomplicated case of measles the chest symptoms are usually 
mild. The cough is at first hard and hacking, and during the eruptive 
period is often paroxysmal, with a loud barking character. After the 
eruption has begun to fade, the cough becomes looser and less frequent ; 
and if proper care be taken to avoid chills, it soon ceases to be heard. The 
physical signs about the chest are those of pulmonary catarrh. One con- 
sequence of the irritation in the lungs set up by the catarrh is seldom 
absent, especially in scrofulous children. This is enlargement of the 
bronchial glands. If there be much throat affection, there may be a simi- 
lar swelling of the glands at the angle of the lower jaw and at the sides of 
the neck. 

The urine during the fever is high colored, with abundant urates. It 
may contain a trace of albumen. 

In some epidemics cases are seen which present all the characters of 
the complaint with the one exception that the rash is absent. These are 
no doubt cases of irregular measles. Cases have been also described in 
which the rash is present, but the catarrhal symptoms are absent (morbili 
sine catarrho). It is very questionable if these latter are classed rightly 
under the head of measles. 

There is a form of measles which is distinguished by great prostration. 
Here the complaint assumes from the first an asthenic type. The pulse is 
small, feeble, and very frequent ; the respirations are rapid ; the tongue 
is dry, brown, and thickly furred ; the temperature of the body is high, 
although the extremities feel cold to the touch ; and the child is dull and 
seems stupefied. When the rash comes out, it is imperfectly developed 
and of a dark red or violet hue. The skin is thickly spotted with pe- 
techias Soon the pulse becomes so rapid that it can only be counted 
with difficulty ; the muscles become tremulous ; there is muttering de- 
lirium, and the patient dies comatose or convulsed. These cases, fortu- 
nately very rare, almost invariably prove fatal. They are generally accom- 
panied by hemorrhages from the mucous membranes as well as into the 
skin. Epistaxis is often obstinate ; hsematuria may occur ; and after death 
ecchymoses may be found in various internal organs. 

In a healthy child an ordinary attack of measles is a mild disorder with 
little severity of the general symptoms. The sharpness of the illness 
appears to be determined to some extent by the constitutional tendencies 
of the patient. One of the pathological consequences of the specific fever 
being the active congestion of the mucous membranes, we might expect 
that a constitutional state in which there is already a predisposition to 
derangement of these membranes would determine more serious symp- 
toms than are found in cases where there exists no such predisposition. 
Children who start in life weighted with a scrofulous diathesis are gener- 
ally bad subjects for measles. It is in these patients that catarrhal symp- 
toms assume such prominence, and that ophthalmia, otitis, and the other 
troubles referred to above are so liable to be met with. Even in the 
mildest cases a certain depression follows the subsidence of the fever. 
The temperature sinks to a subnormal level, and the pulse is very slow 
and intermittent. 

Of all the eruptive fevers measles is, next to typhoid fever, the one 
most liable to return. Many children have it a second time, often after 



MEASLES — COMPLICATIONS. 25 

only a short interval ; and in some cases the second attack may occur at so 
early a period after the first as to constitute a true relapse. Cases are met 
with from time to time in which a child sickens with measles, passes 
through a more or less severe attack, recovers, and after a brief interval of 
convalescence sickens with it again — and all this within a month. 

Complications. — The complications which may render an attack of mea- 
sles troublesome or dangerous have been already in part referred to. As 
a rule, they are exaggerations of ordinary or extraordinary symptoms of 
the complaint, and are determined either by the character of the ej)idemic, 
or by the constitutional peculiarities of the patient. 

Convulsions have been already mentioned as occasionally marking the 
beginning of the disease. The fits may be repeated several times ; but 
when limited to the first day or two of the disorder, although alarming to 
the friends, are seldem dangerous. Should they be repeated, however, 
during the eruptive stage, they must be regarded with more anxiety, for 
they may then prove fatal. 

Epistaxis, a common symptom and generally insignificant, may become 
profuse and exhausting. In severe epidemics, w 7 here the type of the dis- 
ease is a low one, this may be of serious moment. In any case it must 
tend appreciably to protract the period of convalescence. 

Diarrhoea is also, as a rule, a symptom of little consequence ; but some- 
times the mild intestinal catarrh to which it is owing may be converted 
into a real colitis. The stools are then bloody and glairy, and there is colic 
with great tenesmus and pain in defecation. 

Laryngitis is a marked symptom in some epidemics. There is gener- 
ally a certain amount of hoarseness early in the disease from participation 
of the laryngeal mucous membrane in the general catarrh. If this get 
worse the voice becomes husky and almost extinct, the cough hoarse and 
"croupy," and the breathing noisy and oppressed. Great alarm is natu- 
rally excited by this condition of the patient, but the danger is really 
slight. When the rash begins to fade, an improvement is noticed in the 
throat symptoms ; and they often disappear quite suddenly when the tem- 
perature falls. It must not be forgotten that laryngitis with marked spasm 
may arise quite at the beginning of the attack, and be out of all proportion 
to the signs of general catarrh. In such cases the existence of measles 
may not be even suspected until the eruption comes out and discloses the 
nature of the disorder. 

Ophthalmia and otitis are less common symptoms. When these occur, 
it is usually in children of marked scrofulous tendencies. The first may 
form an obstinate complication, and the second may lead to very serious 
consequences. (See Otitis.) 

Extension of the bronchial catarrh to the smaller tubes is a very grave 
accident. It is common in babies and young children, and almost invari- 
ably proves fatal, for in early life collapse of the lung is easily provoked, 
and once established quickly terminates the illness. The first indication 
of danger in these cases is oppression of the breathing, w T hich becomes 
very rapid. There is lividity of the face, and the countenance is haggard 
and distressed. With the stethoscope we hear abundant fine subcrepitant 
rhonchus over both sides of the chest. When these symptoms are present, 
very active measures must be taken to avert a fatal issue to the com- 
plaint. 

In children who have passed the age of twelve months catarrhal pneu- 
monia is a more frequent complication than the preceding. If, in any 
case, on the fading of the rash the temperature undergoes little diminu- 



26 DISEASE IN CHILDREN-. 

tion, we may expect catarrhal inflammation of the lung's to be present. In 
such a case the child, instead of becoming better and more lively as the 
eruption disappears, seems to be weaker and less well than before. His 
face, the swelling having subsided, is seen to be pinched and haggard 
looking ; there is lividity about the lips ; the nares act in inspiration, and 
the breathing is quick and labored. A thermometer in the axilla marks 
about 102°, seldom higher. The patient is thirsty, but will take little food. 
He shows no interest in his toys, but often lies picking at his lips and fin- 
gers, indifferent to everything but his own uncomfortable sensations. Ex- 
amination of the chest reveals all the signs of acute catarrhal pneumonia. 

This complication may also come on at an earlier stage, when the erup- 
tion is beginning to appear. The development of the rash is then retarded, 
or the exanthem may even retrocede with great aggravation of the general 
symptoms. Catarrhal pneumonia is fully described in another part of the 
volume, but it may be mentioned in this place that catarrhal inflammation 
complicating measles often runs a subacute course, and persists long after 
all signs of the primary complaint have disappeared. It may end in death, 
in complete recovery, or may become a chronic lesion forming one of the 
varieties of pulmonary phthisis. 

Sequelae. — The sequelae of measles are constituted in part by the above- 
mentioned complications, which, like catarrhal pneumonia, may become 
chronic and give rise to trouble and anxiety. Chronic laryngitis ' and 
bronchitis are common sequences. Enlarged bronchial glands often re- 
main for a considerable time relics of the disease which has passed away. 
Also, it may again be repeated that in children of scrofulous tendencies an 
attack of measles may light up the cachexia, and give rise to any or all of 
the troubles which are characteristic of that constitutional state. Even 
children who are free from this unfortunate predisposition may not escape 
unhurt from the attack. A condition of the system is often left which ap- 
pears to favour the occurrence of secondary disease ; and whooping-cough, 
croup, gangrene of the mouth and vulva may occur at such a short interval 
after the attack that they cannot but be looked upon as direct sequelae of 
the illness. 

Acute tuberculosis requires special mention as an undoubted and fatal 
consequence of measles. Measles, indeed, is followed by true tubercular 
disease with such frequency that in every case where we are called to a 
child who has been left weak and feverish after a recent attack of the ex- 
anthematous disorder, we may expect him to be the subject either of 
catarrhal pneumonia or of acute tuberculosis. 

Diagnosis. — Before the stage of eruption measles is not easy to detect. 
A severe cold in the child is often accompanied by fever, and there is 
nothing in the catarrhal symptoms of measles which can be considered 
peculiar to that complaint. If such symptoms occur at a time when we 
know an epidemic to be raging, the probabilities are no doubt strongly in 
favour of an attack of this disorder ; but in the opposite case, if we cannot 
ascertain that the child has been exposed to contagion, it is wise to wait 
before expressing an opinion. Still, we should never forget in any case of 
high temperature in a child with signs of general catarrh, that these are 

1 In all cases of hoarseness left after measles trie vocal cords should, if possible, be 
inspected with the laryngoscope. The supposed laryngitis will be sometimes found to 
be really anaemia of the larynx, due to general debility, combined with weakness of the 
adductor muscles, which fail to approximate the cords. This local condition may be 
present although the signs of general anaemia are not pronounced. In such cases we 
should watch the child anxiously for any symptoms indicative of tuberculosis. 



MEASLES — DIAGNOSIS — PEOGNOSIS. 27 

the early symptoms of measles ; and we should inquire as to the existence 
of the disease in the neighbourhood. 

The presence of the catarrhal phenomena will enable us to exclude 
scarlatina should the combination of sore throat and high temperature have 
led us to suspect the onset of that disorder. If laryngitis with stridor and 
spasm be an early symptom, the persistence of high fever after the spas- 
modic attack is at an end will suggest that these manifestations may be 
symptomatic of some latent febrile disorder, and we shall remember that 
measles is sometimes ushered in by laryngeal troubles. 

When the rash appears we shall be less liable to fall into error. The 
crescentic, slightly elevated patches with the skin between them of a 
healthy tint, combined with coryza and cough, are very characteristic. If 
the eruption come out first as hardish isolated papules, small-pox may be 
suspected, and indeed this is a mistake which is often made. But the 
papules have not the hard shotty feeling peculiar to the variolous erup- 
tion ; there is no history of pain in the back ; and vomiting, if it have oc- 
curred, is much less severe than the vomiting of the pre-emptive period of 
small-pox. Moreover, in variola the temperature falls notably on the ap- 
pearance of the rash ; while in measles, if any change occur at all in the 
fever, it is in the opposite direction ; and the catarrhal symptoms become 
aggravated. Doubt is only permissible at the very beginning of the erup- 
tive stage ; for on the second day the rash of small-pox has completely 
changed its character on the face of the patient, the papules having become 
converted into vesicles. 

The rash of roseola may bear a close resemblance to that of measles, 
but in the former complaint there is no catarrh, and the temperature is 
normal or only slightly elevated. Between epidemic roseola (or rotheln) 
and measles the difficulty of distinguishing is often very great. This sub- 
ject is referred to in the chapter treating of the former disorder (see 
page 30). I have also known the early signs on the skin of an acute gen- 
eral eczema to present the closest possible resemblance to measles. But 
an exanthem should never be judged of by the rash alone. In every case 
we should search for confirmatory symptoms, and inquire as to the tem- 
perature and the initiatory phenomena of the illness. In measles we ex- 
amine the eyes for injection, the throat for redness, and ask about cough, 
hoarseness, and catarrhal symptoms generally. If these are completely ab- 
sent, and the temperature be below 100°, it is very unlikely that the disease 
is measles, however typical the rash may appear. 

The stains left on the skin as the rubeolous eruption dies away have 
been compared to the mottling of syphilitic roseola, but the history and 
course of the illness are so different in the two cases that hesitation is im- 
possible. 

Prognosis. — The percentage of mortality in measles is small. Still, it 
is much higher in some epidemics than it is in others ; and, therefore, in 
estimating the chances of a patient's recovery we must take into account 
the character of the epidemic. Another consideration is the previous 
state of health, especially the constitutional tendencies of the child. 
Unless the case be one of malignant measles, or the child have been pre- 
viously in a state of great weakness, there is every hope of preserving 
life if ordinary care be exercised in nursing the patient through his ill- 
ness. But it is less easy to avert injury to the health from the dangerous 
sequelae of the disease. In spite of all we can do, a child of strong scrof- 
ulous predisposition may be left greatly the worse for the attack ; and if 
his lungs be already the seat of caseous consolidation, it will be difficult 



28 DISEASE IN CHILDKEN. 

indeed to prevent his phthisical tendencies from receiving a distinct 
impulse. 

In children under two or three years of age bronchitis is a common 
complication. Here the child's previous health is a point of very great 
importance. One danger in these cases is the occurrence of collapse of 
the lung, and this is predisposed to by the presence of rickets, or by gen- 
eral weakness of the patient. If the child be the subject of marked rickets, 
and bronchitis supervene, his chances of recovery are small. Another 
danger is the tendency of the bronchial inflammation to spread into the 
finer bronchial tubes and air- vesicles, and give rise to catarrhal pneumonia. 
The occurrence of this accident greatly increases the gravity of the case ; 
but if the child be a healthy subject, and the epidemic be a mild one, the 
chances are in favour of recovery, for in measles catarrhal pneumonia tends 
to run a subacute course. If, however, the child be weakly, or the case 
occur in the midst of an epidemic of unusual severity, we should speak 
very guardedly of his hopes of escape. 

Treatment. — In the early stage of measles the treatment is that of a 
severe cold on the chest. The child must be kept in bed, put upon a diet 
of milk and broth with dry toast, and take for medicine a saline with some 
unstimulating expectorants. While the cough is hard and the chest tight, 
the stimulating expectorants, such as ammonia, squill, and senega, should 
on no account be made use of, as they increase the tightness of the chest 
and make secretion more difficult than before. If vomiting be distressing, 
an emetic may be given to relieve the stomach of unhealthy secretions. 
Mustard, or sulphate of copper (gr. J to gr. ^ every ten minutes), is to be 
preferred for this purpose, as ipecacuanha has a very irritating effect upon 
the bowels of some children. If there be diarrhoea, a small dose of castor- 
oil or of rhubarb and soda will be of service at the beginning of the attack ; 
but the aperient should not be repeated, for in measles the bowels are very 
susceptible to the action of purgatives. If the diarrhoea continue, a mix- 
ture of aromatic chalk powder and rhubarb, five grains of each, may be 
given to a child three years of age every night for three nights ; or he may 
take oxide of zinc with glycerine (two grains three times a day), and either 
of these will usually arrest the purging. Still a moderate looseness should 
not be interfered with. It is better not to employ astringent remedies un- 
less the stools are very watery, and threaten by their number to reduce 
the patient's strength. 

The general management of the child must be conducted according to 
the rules already laid down for the nursing of febrile complaints (see Intro- 
duction). In cases of measles special care should be taken to avoid draughts 
while insuring free ventilation of the room. A strong light hurts the 
reddened eyes, so care should be taken to keep the room in a half light, 
without making it actually dark. Due attention must be paid to cleanli- 
ness. It is not necessary in cases of measles to keep the child dirty. The 
skin should be cleansed every morning ; using tepid water, and being care- 
ful to wash and dry separately each part of the body, so that the whole 
surface may not be exposed at one time. The patient may be allowed to 
take fluid often, but he must be prevented from drinking large quantities 
at once. The best drink is pure filtered water, and if a small cup or glass 
be used, the child will be satisfied if allowed to drain it to the bottom. 

The condition of the throat usually requires little treatment. A strip 
of lint wrung out of cold water may be applied closely round the neck, and 
be covered with oiled silk and flannel. This can be re-wetted as often as 
is necessary. The same application is useful if there be much inflam- 



MEASLES— TKEATMENT. 29 

mation of the larynx ; and if spasm occur with stridulous breathing, the 
throat may be fomented by applying below the chin a sponge dipped in 
water — hot, but not hot enough to scald. 

A single convulsion does not require treatment; but if the fits are 
repeated, the child should be placed for a few minutes in a warm bath and 
then be returned to his bed. A hot bath is useful if capillary bronchitis 
or catarrhal pneumonia occur early, and interfere with the development of 
the rash. If they occur later during the subsidence of the eruption, the 
child's back should be dry-cupped, or be covered with a large poultice 
made of one part of mustard to five or six parts of linseed meal. This can 
be kept in position for eight or ten hours, and afterwards the front of the 
chest can be poulticed in the same way In cases where the danger is 
great, the dry cups are to be preferred to the more slowly acting poultice ; 
and I believe life may be often saved by the timely use cf this energetic 
measure. 

Stimulants are not required in ordinary cases of measles, but when the 
patient is of weakly habit of body or of distinct scrofulous type, or when 
he is suffering from an unusually severe attack of the disease, it may be 
necessary to support the strength by alcohol. The brandy-and-egg mix- 
ture of the British Pharmacopoeia is very useful for this purpose, and may 
be given in such doses as the child's age and condition require. Children 
— even very young children — who are weakly or prostrated by illness re- 
spond well to stimulants, and can take them in considerable quantities with 
great advantage. I have often seen an infant of eight or nine months of 
age greatly benefited by a teaspoonful of brandy-and-egg mixture given 
every hour Of this quantity a third part is pure brandy. If without the 
occurrence of any severe complication the patient seems to be getting into 
a typhoid state, with dry tongue and small rapid pulse, stimulants are 
urgently needed. Also, the presence of bronchitis or pneumonia will 
demand a recourse to the same remedy, or the child may sink and die 
with startling suddenness. 

Food must also be given with care and judgment, taking pains not to 
overload the stomach, but to proportion duly the nourishment, both in 
quantity and quality, to the age and strength of the child. In all cases of 
weakness the milk should be diluted with half or a third part of barley 
water, so as to insure a proper division of the curd. In addition, it may 
be guarded by fifteen or twenty drops of the saccharated solution of lime 
to prevent its turning acid upon the stomach. This must be given in 
small quantities at regular intervals. Strong beef-tea, or beef-essence 
made in the house, is also very useful when the strength is failing, but it 
must be given in very small doses at sufficient intervals. Brandy can be 
added if necessary. 

When the rash begins to fade and the temperature falls, the child, if 
old enough, may take pounded meat, the yolk of an egg lightly boiled, and 
a little light pudding. 

The chronic sequelae must be treated according to the rules laid down 
in such cases, and the reader is referred to the chapters treating of these 
subjects. It may only be added that quinine is invariably required at the 
end of an attack of measles ; and bracing sea-air is very beneficial in has- 
tening the return of health and strength. This is of especial importance 
in the case of scrofulous children, who will also require cod-liver oil as 
soon as their stomachs can bear it. 



CHAPTER II. 

EPIDEMIC ROSEOLA. 

Epidemic roseola, often called rotheln or German measles, is a mild infec- 
tious complaint which bears so close a resemblance to measles that it is in 
all probability frequently confounded with it. The two diseases are, how- 
ever, not the same, for rotheln does not protect against measles, and is 
itself often seen to occur in a child who has been lately the subject of that 
disorder. The complaint is almost always a mild one, and has no compli- 
cations or sequela?. 

Symptoms. — The stage of incubation is said to last a week. When the 
disease begins, the child is seen to lie about and to look poorly. He is 
slightly feverish and, if old enough, complains of headache. With this 
there are the usual accompaniments of thirst and want of appetite ; and 
sometimes a pain in the back has been complained of — violent in character 
like the back-ache of small-pox. The pre-eruptive stage often lasts only a 
few hours, or, indeed, may be even absent. Perhaps its Average duration 
may be taken at twenty-four hours. The eruption then comes out on the 
cheeks, and sides of the nose, as dusky-red slightly elevated papules, the 
colour of which disappears on pressure. The wrists and ankles are attacked 
almost as early as the face ; and from these points the rash quickly spreads 
to the rest of the body and limbs. On the cheeks the rash is more 
papular than elsewhere. It differs from the eruption of measles in that 
the spots do not group themselves in crescentic patches ; but resembles it 
in the tendency of the rash to become confluent in places. Thus a large 
patch of uniform redness is often seen on the cheeks ; and sometimes we 
find the same confluence of rash on the wrists and forearms, the legs and 
the ankles. The eruption is attended with a good deal of irritation, and 
when it subsides, is followed by a slight fine desquamation. 

The general symptoms during this stage are trifling. The fever may 
persist during the first day or two, but often subsides soon after the ap- 
pearance of the rash. The conjunctivae may be injected, but there is seldom 
coryza ; and if cough be present, it is insignificant. One almost constant 
symptom is sore throat. This generally comes on with the rash, and, on 
inspection, the fauces are found to be the seat of diffused redness ; and 
the tonsils may be inflamed and swollen. The soreness subsides in a day 
or two, but after a short interval is apt to return. The secondary sore 
throat is a characteristic symptom of rotheln. It occurs between the 
third and seventh day — usually, according to Dr. Tonge-Smith, on the 
fourth or fifth — and is accompanied by great pain and much swelling. In 
the severer cases the voice is altered, articulation and deglutition are dis- 
tressing, and there is much secretion of sticky mucus. The temperature at 
this time may reach 103° or 104°; still, even when the throat symptoms are 
worst there is no prostration or even any feeling of general illness. Some- 
times the glands of the neck are enlarged and tender , and in some epi- 



EPIDEMIC EOSEOLA — DIAGNOSIS— TEEATMENT. 31 

demies the post-cervical glands have been noticed to be swollen. The 
axillary, inguinal glands, etc., may be also affected. The duration of the 
eruptive stage is three or four days. 

An attack of rotheln is then, as a rule, a very insignificant matter. The 
difficulty is to distinguish it from measles, which it so much resembles. The 
two chief points of distinction are the shorter period of the eruptive stage 
in rotheln, and the non-crescentic arrangement of the rash. The milder 
character of the catarrh will hardly serve as a distinguishing mark, for 
sometimes in measles the cough and coryza cause little inconvenience to 
the patient Another point is the lower temperature. Sometimes in ro- 
theln there seems to be scarcely any fever at all ; and when present, the 
pyrexia generally subsides on the second day. In spite of these points of 
contrast between the two complaints, we must often hesitate to express a 
positive opinion upon a particular case. The absence of any increase of 
fever when the eruption comes out may afford a suspicion that the case is 
not one of true measles, but we can seldom speak with certainty upon the 
first day of the rash. On the second or third day, however, if we find the 
general symptoms still retain their trifling character, and if the fever sub- 
sides before the rash has begun to fade, we may conclude the case to be 
one of rotheln. In doubtful cases the more or less general glandular en- 
largement, especially the swelling of the cervical and suboccipital glands, 
is a very suspicious symptom ; and the occurrence of secondary sore throat 
with no actual sense of illness is very suggestive of rotheln. 

The disorder has been described as a mild one, but it is right to say 
that some authorities hold that it may assume a much more severe charac- 
ter, Dr. Cheadle, from careful observation of two epidemics, which pre- 
sented all the characters of measles and occurred in succession in the 
same district within the same year, concluded that the second of these epi- 
demics was rotheln although the symptoms were severe, and the laryngeal 
phenomena especially well marked. He founded this opinion upon the 
shorter period of incubation during the second epidemic, and upon the 
fact that out of thirty cases in which absolutely trustworthy histories 
could be obtained, twenty-two had had measles before, and ten of these 
under his own immediate observation within the year. Still, we may re- 
member with regard to this latter point that measles, although as a rule it 
protects the subject for the future against a similar attack, is perhaps of 
all the contagious fevers the one most liable to recur. A second or even 
a third attack in the same individual is far from uncommon, and sometimes 
the interval between two such attacks is curiously short, 

Treatment. — The patient must be confined to one room while the fever 
lasts, and care must be taken that he is not overfed. No medicine is 
required. 



CHAPTER III. 

SCARLET FEVER. 

Scaelet fever (or scarlatina) is, like measles, one of the commoner in- 
fectious fevers of childhood. It usually occurs in epidemics which vary 
greatly in severity. One attack, in the large majority of cases, protects 
against a second, for it is a disease which very rarely occurs twice in the 
same person. A second attack may, however, occur. Some time ago I 
saw a little girl, aged seven years, who had a significant history of fever 
followed by desquamation and dropsy, which had attacked her when she 
was in perfect health two years before. The child was a patient in the 
East London Children's Hospital, suffering from general amyloid disease 
dependent upon spinal caries which had followed the illness referred to. 
While she was in the hospital the girl again contracted scarlatina, and was 
sent away to the Fever Hospital, where she died. 

Sometimes the disease appears in an abortive form in persons who are 
already protected by a previous attack. In every epidemic of scarlatina it 
is common to find cases of anomalous sore throat occurring in protected 
persons exposed to the infection. Such persons may communicate the 
perfect disease to others who are not protected. 

Causation. — The fever is of a highly infectious nature, and is readily 
communicable from one individual to another. Sporadic cases are some- 
times met with, but the illness generally occurs in epidemics. The infec- 
tious principle is probably not at all volatile, for articles of clothing, flan- 
nel, etc., have been known to retain their poisonous properties for long 
periods of time. It is a debated question whether the disease ever has a 
spontaneous origin. Some authorities hold that it may be generated de 
novo by cesspools and ill-ventilated drains. Different epidemics have dif- 
ferent degrees of severity • but apart from the special type of fever preva- 
lent, the intensity of the disease is dependent more upon the constitu- 
tional state and sanitary surroundings of the recipient than upon the 
severity of the disease in the person from whom the infection is conveyed. 
Scrofulous children, and those who are ill cared for, or are exposed for 
long periods to an impure atmosphere, are likely to take the disease 
badly. 

During the first few days of the illness the patient is less dangerous as 
a source of infection than he afterwards becomes. The time of desquama- 
tion is probably the period at which the complaint is most likely to be car- 
ried away, for the particles of epithelium thrown off must be highly con- 
tagious, and the patient's power of communicating the disease does not 
cease until the peeling of the skin is at an end. 

Scarlatina is seen less frequently than measles during the first twelve 
months of life ; but between the first and second years the disease is a 
common one, and, according to the researches of Dr. Murchison, 64 per 
cent, of the cases occur before the completion of the fifth year. After the 



SCARLET FEVER — MORBID ANATOMY —SYMPTOMS. 33 

tenth year the disease again becomes less frequent, although it may occur 
during adult life or even in extreme old age. 

Morbid Anatomy. — After death from scarlatina we usually find evi- 
dence of the special complications which have determined the fatal issue. 
In addition the blood coagulates imperfectly, as a rule, although pale 
fibrinous clots may be found in the right ventricle. 

The parts especially prone to suffer are the gastro-intestinal mucous 
membrane and the glandular system. In fatal cases inflammatory swell- 
ing is found in the lymphatic glands of the neck ; also in the follicles at 
the base of the tongue, and in those of the pharynx, tonsils, and larynx. 
In the intestine the solitary glands and those of Peyer's patches are often 
enlarged, reddened, and softened. There may be also enlargement and 
softening of the spleen, liver and pancreas. In all these organs, according 
to Dr. Klein, there are changes in the small blood-vessels. A hyaline 
thickening is noticed in the arterioles, with a proliferation of the cells of 
the endothelium and of the nuclei in the muscular coat, together with an 
accumulation of lymphoid cells in the tissues around. In the gastro- 
intestinal mucous membrane there is hyperemia of the subepithelial 
layers, and great proliferation of cells which distend and obstruct the 
gastric tubules. Sometimes casts of these tubules may be detected in the 
matters ejected from the stomach. 

The cutaneous affection is not a mere hyperemia. It is also an exuda- 
tion into the rete mucosum. The cells in this situation are proliferated 
and swollen, and the sweat-glands may be stuffed and distended by their 
increased cellular contents. Serous effusions with migration of leucocytes 
may also occur. The lymphatic glands, especially those of the neck, are 
enlarged ; the lymphoid cells disappear, and in places large giant cells be- 
come developed containing many nuclei. 

The kidney presents the characters of acute Bright's disease. The 
whole organ is congested, and important changes are noticed in the glom- 
eruli, the small arteries, and the convoluted tubes. According to Dr. Klein, 
these changes take place very early, so that in the first week of the disease 
proliferation of the nuclei in the MaApighian tufts and in the muscular 
coat of the arteries can be detected, as well as hyaline degeneration of the 
intima. At the same time there is hyaline thickening of the walls of the 
Malpighian capillaries, and cloudy swelling of the epithelium in some of 
the convoluted tubes. At a later stage the cloudiness and swelling of the 
tubal epithelium increases, and fatty degeneration takes place ; infiltra- 
tion of lymphoid cells occurs into the interstitial tissue around the tubules ; 
and the tubules themselves are filled with hyaline casts. 

In cases of ursemia the blood is sometimes found to contain an enor- 
mous excess of urea. In a case reported by M. D'Espine of Geneva, in 
which venesection was employed, the blood was found to contain 3.3 parts 
of urea per thousand, cr about twelve times the normal quantity. The 
potash salts, also, were increased to three times the natural proportion, 
and of this two-thirds was contained in the serum, and not, as in healthy 
blood, in the red corpuscles. From the experiments of Feltz and Hitter, 
and others, it appears probable that the symptoms of ursemic poisoning are 
due not to the retained urea, but to the excess of potash salts in the blood. 

Symptoms. — After exposure to infection a period of incubation pre- 
cedes the actual outbreak of the fever. This stage is of very variable 
duration. It may last only twenty-four hours, or be prolonged to a week 
or more. Probably six days may be taken as the ordinary duration of this 
period. 



34 DISEASE IJST CHILDKEN. 

Different cases of scarlatina vary so much in severity and in the vio- 
lence of special symptoms that it will be convenient to divide the disease 
into two chief forms : The common mild form and the malignant form. 
Afterwards the complications and sequelae will be described. 

In the common form the invasion of the disease is abrupt. It begins 
with a chill ; the child complains of sore throat, and generally vomits. 
Sometimes there are nervous symptoms, and in exceptional cases the 
disease may be introduced by a convulsion or a state resembling coma. 
The tongue is generally furred at the back, red at the tip and edges ; the 
appetite is lost, and there is thirst. The skin is hot, and the pulse rises to 
130°, 140°, or even higher. The rash sometimes appears within a few hours 
of these early symptoms: occasionally it is itself one of the early phe- 
nomena ; and again in rare cases it may be delayed for three or four days, 
or, it is said, even for a week. As a rule it is noticed within twenty-four 
hours of the beginning of the disease. The temperature rises progres- 
sively through the invasion stage until the rash appears. The pyrexia is 
not, however, excessive, In the case of the little girl, before referred to, 
who was taken with scarlatina while in the hospital, her temperature had 
always been normal, but one evening it was noticed to be 100.2°. The. 
next morning it was 101.2°, and the child vomited several times. Toward 
the evening the rash appeared, and the mercury reached 103°. In another 
case — a little boy aged eight months, who was teething — the temperature 
for several days had been 100°. One morning it rose to 102.2°; he 
vomited, and in a few hours the rash appeared. To the hand, perhaps, 
the skin gives the impression of being hotter than it actually is, for the 
heat is often accompanied by a peculiar dryness, which gives a burning 
character to it like that of pneumonia. Tested by the thermometer, the 
temperature will be rarely found to exceed 105°. 

With the appearance of the rash the invasion stage comes to an end 
and the eruptive stage begins. The rash first appears as scarlet points, 
not elevated above the surface. These are closely set, and their borders, 
which are paler than the centre, unite so as to produce, when fully devel- 
oped, the appearance of a uniform pink ground dotted thickly over with 
scarlet points. The rash rarely affects the face to the same degree that 
it does the rest of the body, and differs in this respect from the eruption 
of measles. Usually the region about the mouth is comparatively free, 
and contrasts by its paleness with the deep red tint of neighbouring parts. 
The colour of the rash disappears on pressure of the finger. When the 
eruption is confluent, as it is in a typical case, no intervening healthy skin 
can be seen. Often, however, the eruption is not confluent. The puncta 
are then more or less isolated, and may be separated by spaces in which 
the skin has the normal colour. The rash may be confluent in some places, 
not in others. On the cheeks, neck, chest, abdomen, and inner aspect of 
the arms and thighs, coalescence of the neighbouring puncta is usually 
complete. In other parts the spots may be more or less isolated. Some- 
times the eruption is everywhere discrete. The puncta are then usually 
larger ; and if at the same time the temperature is only slightly elevated 
and the sore throat insignificant, great doubt may be entertained as to the 
nature of the disease ; especially as when thus discrete the spots are often 
a little elevated. These cases have been mistaken for measles. 

Again, the colour of the rash may vary. It may be very pale, so as to 
be only discovered by careful examination ; or it may be dusky and pur- 
ple. Often it is more pink than scarlet. Sometimes it is limited to certain 
parts of the body, such as the sides of the neck, the chest, or abdomen, 



SCARLET .FEVER— SYMPTOMS. 35 

and cannot be detected upon the limbs. It is usually said to begin about 
the root and sides of the neck and on the chest ; but if so, these parts 
precede the rest of the body by a very short interval, and the rash be- 
comes general very quickly. It is at its height on the third or fourth day 
of the illness. There is then often a good deal of irritation of the skin, 
and some subcutaneous oedema is present, which makes the fingers stiff 
and clumsy-looking. The rash may be accompanied by miliaria about the 
neck and chest ; the skin is often rough from enlargement of the sub- 
cutaneous papillae (cutis anserina) ; and petechiae are not unfrequently 
present. These small fasemorrhagie spots do not necessarily indicate any 
special severity in the attack. Sometimes also vesicles or even papules 
may be noticed. When the eruption is at its height, a hue drawn upon 
the reddened surface by the finger-nail remains visible as a white streak 
for about a minute. This sign has been considered to be pathognomonic. 
The rash begins to fade on or after the fifth day of the illness, and has 
usually completely disappeared by the tenth. 

During the eruptive stage the symptoms of the invasion period increase 
in intensity. The tongue cleans and becomes deep red with swollen pa- 
pillae, so as to present the well-known strawberry appearance. The child 
is very thirsty, but in the milder cases has a fair appetite. Vomiting is 
seldom repeated after the first day ; but in exceptional cases this symptom 
is an obstinate and distressing one, adding greatly to the gravity of the 
case. If severe, it may reduce the temperature. The soreness of throat 
usually increases during the eruptive stage ; and examination of the 
fauces shows a bright redness of the soft palate, uvula, tonsils, pillars of 
the fauces, and often of the back of the pharynx. Sometimes these parts 
are also swollen from oedema, so that the uvula is broad and the tonsils 
nearly meet in the middle line. There is also in most cases excess of ton- 
sillitic secretion, and yellow pulpy matter may be seen collected at the 
mouths of the follicular recesses, or even coating the surface in a uniform 
layer. If the matter do not escape, it may form an abscess in the tonsil, 
as in common quinsy. In the more severe cases the tongue loses its moist 
appearance and the mucous membrane of the mouth, and throat gener- 
ally, looks dry and shining. Unless in the worst cases, ulceration does not 
occur until the disease is subsiding. Sometimes at an early period the 
disease is complicated with diphtheria. If the throat affection is severe, 
there is much pain and tenderness in swallowing ; the voice is nasal in 
quality ; and the glands of the neck become enlarged and tender. The 
inflammation may extend from them into the connective tissue around, and 
end eventually in suppuration. In an ordinary case the throat improves 
as the eruption fades ; but the tonsils and the lymphatic glands may re- 
main enlarged, although painless, for some time after the inflammation has 
subsided. 

The degree of pyrexia as a rule is moderate. The temperature seldom 
rises above 105°, although in exceptional cases it may reach a higher ele- 
vation. Unless it be maintained by the presence of a febrile complication, 
the temperature tends to subside when the rash begins to fade ; and a 
crisis then usually occurs, the heat of the body being normal for twenty- 
four hours. Should this crisis not occur, the pyrexia may be prolonged 
for several days. Even in a mild uncomplicated case I have known the tem- 
perature to remain elevated two degrees above the normal level for twelve 
days. As long as the fever continues, the pulse is as frequent as at the 
beginning, and slackens when the temperature falls. It often reaches 160, 
and this frequency is not to be taken as a sign of danger. So, too, deli- 



36 DISEASE IN CHILDEEN. 

rium may be present, and if slight and occurring only at night, is not of 
serious import. The child often complains of headache and of aching pain 
about the limbs. 

The urine is scanty and high coloured. It may contain excess of bile pig- 
ment, and there is often a sediment of lithates or of free uric acid. Ac- 
cording to Dr. Gee, the chlorides are sensibly reduced in quantity, and the 
phosphoric acid undergoes a decided reduction. The urea is not neces- 
sarily increased. 

The desquamative stage begins a few days after the rash has faded. 
The exact period at which it can be first noticed is very variable. The 
first sign of peeling may be seen while the skin is still tinted with the re- 
mains of the eruption and before the pyrexia has subsided ; or it may be 
delayed for some days or even weeks after the rash has disappeared. It 
usually occurs early in proportion to the intensity of the eruption, and if 
miliaria has been present, is often early and profuse. In the slighter cases 
it may be long delayed, and Dr. Page states that after a mild attack he has 
known desquamation to be postponed for five weeks. The epithelium at 
first looks dry and may be finely wrinkled. Then, on the neck, upper 
part of the chest, and front of the shoulders, the skin begins to fall in fine 
bran-like scales. Over those parts where the cuticle is thin and deli- 
cate the desquamation is very fine. "Where the skin is thicker the parti- 
cles thrown off are larger, and in some places, such as the hands and feet, 
large areas.of epithelium may be cast off unbroken. On close inspection 
of the peeling surface the cuticle will be seen to be raised in the form of 
an empty vesicle. The crown of this elevation falls, leaving a minute circle, 
which gradually extends itself, until its circumference meets other circles 
widening in the same way. If the crown of the vesicle does not break off, 
the separation of the epithelium may go on, at the periphery until, by the 
coalescence of neighbouring centres of desquamation, large tracts of skin 
are thrown off. 

The process may be over in ten days or a fortnight, or may be pro- 
longed for weeks. It often lingers long about the fingers and toes. A 
secondary desquamation is even said to occur in some cases, and the peel- 
ing undergoes a species of relapse. Until the last flake of epithelium has 
been cast off the patient cannot be said to be completely free from in- 
fection. 

In this stage the pulse is at first often slower than natural, and may 
intermit. The temperature, also, after the cessation of the pyrexia, remains 
subnormal for some days. 

In malignant scarlatina the severity of the disease is shown either by 
violence of nervous phenomena which prove rapidly fatal ; or by the early 
appearance and intensity of the throat affection, which causes death in the 
first or second week of the illness. 

In the first form the disease from the beginning may show the utmost 
violence. The vomiting is repeated and distressing ; the child is agitated 
and delirious or convulsed ; the temperature rises to 107° or 108° ; the 
breathing is quick and shallow ; the pulse is rapid. After some hours or 
days, according to the violence of the symptoms, the patient sinks into a 
stupefied condition with haggard, dusky face, cold extremities, a feeble, 
rapid pulse, and a moist skin. He vomits frequently or may be violently 
purged, and dies comatose or in convulsions. In the worst cases the pa- 
tient seems literally overwhelmed by the intensity of the fever poison, and 
dies before the rash appears or the' sore throat has assumed any special 
prominence. Thus, a child may be found a few hours after his first attack 



SCARLET FEVER — COMPLICATIONS AND SEQUELAE. 37 

collapsed or unconscious, vomiting incessantly, and passing frequent, thin, 
watery stools. The throat presents a dusky redness ; the pulse is very 
rapid and feeble ; and the thermometer in the rectum marks 102° or 103°. 
In a few hours the temperature rises to 105° or 106° ; convulsions come 
on, and the child dies. In other cases he lingers longer, and may appear to 
rally for a time ; but the depression continues, the stupor returns, and 
death occurs by the end of the week. 

When the disease assumes a malignant form from exaggeration of the 
throat affection, the course of the disease for the first few days presents 
nothing abnormal ; but on the fifth or sixth day the fauces become exces- 
sively tender, and deglutition is very difficult and painful. The lymphatic 
glands at the angle of the jaw and the connective tissue around them are 
inflamed and swollen. On examination of the throat the mucous mem- 
brane is seen to be of a deep red or dark purple colour, and patches of 
ashy gray exudation matter are dotted over the surface of the soft palate, 
uvula, and tonsils. In the bad cases ulceration takes place in these spots, 
and, spreading, causes wide destruction of tissue. The face is often livid 
and haggard ; the pulse is quick, feeble, and fluttering ; there are sordes 
on the teeth and lips ; the tongue is dry and brown ; the fetor of the breath 
is extreme ; and an offensive purulent discharge escapes from the nose. At 
the same time the neck swells and feels brawny to the touch ; the skin 
melts away in places ; and thin, purulent matter, with shreds and lumps of 
sloughy connective tissue, are discharged through the openings. The 
sloughing of the subcutaneous tissue of the neck is often accompanied 
by other serious symptoms. Hemorrhage may take place from the large 
vessels ; oedema of the glottis may occur ; the patient may fall into a ty- 
phoid state or die from pyemia. In one way or another such cases usually 
terminate fatally. 

When the throat affection assumes a malignant form the prostration is 
generally marked, and the patient lies in a drowsy state, although he seems 
intelligent enough when roused. The temperature is not excessively eleva- 
ted, seldom rising above 103° ; but the pulse is very rapid and feeble. It 
is important to know that the swelling of the cervical glands is not always 
in proportion to the severity of the throat complication, and furnishes no 
ground upon which to establish a prognosis. Deep-seated sloughing and 
fatal haemorrhage may occur in cases where the external glands are only 
moderately enlarged. If the throat affection is severe from the first, the 
appearance of the rash may be delayed for several days ; and it may come 
out in a patchy manner, being most marked in parts where the skin is 
especially thin and delicate, as in the folds of the arm-pits and groins. 

Sometimes we find the above two forms of malignant fever combined. 
The nervous symptoms are in excess, and there is also serious ulceration of 
the fauces and destruction of tissue. Convulsions occurring from any 
cause during the eruptive period are of very serious import, and generally 
end fatally whether the throat symptoms are mild or severe. 

Complications and Sequelae. — The intercurrent disorders which are liable 
to occur during or after an attack of scarlet fever may be looked upon as 
complications or sequelae, according as to whether or not the disease is 
considered at an end when the temperature returns to a normal, level. 
Most of them arise during the second week of the illness, although some 
may occur earlier. They will be described in the order of their occur- 
rence. 

During the first week the fever may be complicated by diphtheria, diar- 
rhoea, and coryza. The ulcerative throat affection, which by many writers 



38 DISEASE IN CHILDBEN. 

is considered as a complication, has been described as a phase of the malig- 
nant form of the fever. 

Diphtheria may be an early complication of scarlet fever, and may spread 
to the nose and larynx. It often comes on during the first week of the 
illness, but may occur later and at a time when the patient is supposed to 
be rapidly approaching convalescence. It generally proves fatal. 

Coryza of a mild character occurring in the course of the first week is 
not a symptom of unfavourable omen ; but if it persist into the second week, 
it becomes more serious. In such cases the catarrh may spread along the 
Eustachian tube into the tympanum and set up otitis. If in any case the 
nasal discharge becomes fetid, it suggests the presence of diphtheria. 

Diarrhoea is sometimes an early complication. It usually ceases after 
a day or two, but may prove so severe as to endanger the life of the patient. 
According to Henoch it is preceded by swelling of the Pyerian and solitary 
glands. Sometimes as the rash fades the diarrhoea, which had at first 
appeared of little importance, passes into a true entero-colitis. The tem- 
perature which had fallen rises again ; there is nausea and often vomiting ; 
the belly is swollen and perhaps tender ; and the child complains much 
of abdominal pain. The tongue, dry and hot, is furred on the dorsum, 
red at the tip and edges. The bowels are loose, and the stools contain 
much food partially digested, mixed up with mucus and sometimes with 
blood. The child looks excessively ill and rapidly loses flesh. He may 
die from the acute attack, or the complication may pass into a chronic 
stage. 

In the second week bronchitis and pneumonia, rheumatism, and serous 
inflammations may be seen. 

Bronchitis and pneumonia, which are common in measles, are compara- 
tively rare complications of scarlatina. It is much more frequent to find 
inflammations of the serous membranes, especially of the pleura and peri- 
cardium ; and these are often associated with symptoms indistinguishable 
from those of rheumatism. 

Scarlatinous rheumatism may occur during the second week or beginning 
of the third, and is often met with as a complication or sequel of the fever. 
Whether the disease is to be looked upon as a true rheumatism quite 
independent of the scarlatina, or as an arthritis resulting from septicaemia, 
or as a further manifestation of the scarlet fever poison which may fasten 
upon the joints as it may fasten upon the kidneys or the throat, is still a 
matter of discussion. The rheumatic attack certainly follows the ordinary 
course of that disease ; it frequently affects the serous membranes in and 
around the heart ; and the joint inflammation subsides, as a rule, after a 
day or two, although in exceptional cases it may end in suppuration. This, 
may, however, occur in cases where there is no suspicion of scarlet fever. 
Endocarditis is as common as pericarditis, and heart disease in the child 
often dates from an attack of scarlatina. Pleurisy and pericarditis some- 
times come on in the third week instead of the second, and may occur in 
cases where joint pains are not complained of. They may then be a symp- 
tom of Bright's disease ; but pericarditis from this cause is not very common 
in the child as a sequel of scarlet fever. If pleurisy occur the effusion very 
rapidly becomes purulent. 

In the third week the patient is especially liable to kidney mischief. 
At this time, too, or shortly afterwards, otitis may occur, and gangrene 
and abscesses may make their appearance. 

The urine should be examined daily throughout the illness for albumen. 
This may be found at any time from the second to the twenty-first day. 



SCAELET FEVEE — ALBUMINOUS NEPHEITIS. 39 

It is, however, in the course of the third week that it is especially liable to 
be met with. 

Albuminuria does not bear any relation to severity of attack. It may 
be present in mild cases and absent in severe ones. By itself it does not 
indicate serious renal mischief, and if small in quantity does not affect the 
prognosis. 

If the albuminuria is due to anything more than a simple congestion 
of the kidneys, which is of little consequence, the urine soon shows signs 
of the presence of nephritis. Its quantity is reduced : its colour is smoky 
from the presence of blood, or even deep red if the haemorrhage is co- 
pious ; boiling throws down a copious precipitate of albumen ; and renal 
epithelium, blood-disks, and casts, granular and epithelial, are discovered 
by the microscope. At the same time or shortly afterwards the face is 
pale or puny-looking ; the eyelids are stiff and swollen ; and more or less 
oedema is noticed about the legs and ankles. 

The beginning of the kidney complication is . generally announced by 
vomiting, headache, loss of appetite, a dry skin, a pallid complexion, an ir- 
regular pulse, and a rise in the temperature. The temperature is not very 
high, seldom exceeding 101°; and the vomiting is not often repeated, al- 
though sometimes it becomes a distressing symptom. The oedema varies 
in amount. Sometimes it is little more than a puinness of the skin. In other 
cases the swelling may be general and severe, so as completely to alter the 
natural expression of the face, and greatly distend the limbs and lower 
part of the back. At the same time effusion may take place into the se- 
rous cavities, the lungs, and even the glottis. If these effusions are rapid 
and copious, great lividity and dyspnoea may ensue, and death may take 
place with startling rapidity. The most violent attacks of dyspnoea may 
be induced by interstitial oedema of the lungs. The patient is found 
gasping for breath, with a haggard, livid face. His eyes are staring and 
congested, his lips blue, and his nails purple. His pulse is weak and 
rapid and his heart's action feeble and fluttering. On examination of the 
chest few physical signs are to be discovered. The rhonchi are scanty and 
scattered, for very little fluid, if any, exudes into the air-passages and al- 
veoli. 

In a certain proportion of cases ura?mic symptoms may occur. The 
child is, perhaps, violently convulsed several times, and may lapse into a 
state of coma ; or he may be seized with headache of a very distressing 
character. Fortunately these symptoms usually pass off under the influ- 
ence of judicious treatment. It is exceptional for a child to die of scarla- 
tinous nephritis. The occurrence of the renal complication appears to be 
dependent in a great measure upon the character of the epidemic ; for 
while in some it is a common symptom, in others it is almost entirely ab- 
sent. The popular impression that it is always the consequence of a chill 
has been disproved over and over again. There is no doubt that if albu- 
minous nephritis be present, a chill may hasten the occurrence of dropsy ; 
but that slight exposure, such as occurs during convalescence from scarlet 
fever, can determine the occurrence of the nephritis is now very generally 
disbelieved. 

In the earlier stage of the nephritis the amount of urine is diminished 
and its specific gravity is raised. After a time the secretion becomes more 
copious and at the same time its density falls. Usually the pyrexia sub- 
sides when the quantity of urine increases. Dropsy is not an invariable 
symptom. It may be completely absent, although the other phenomena 
are well marked. As a rule the nephritis is rapidly recovered from, and 



40 DISEASE IN CHILDREN. 

the albuminuria and uraemic symptoms quickly disappear ; but some- 
times, although improvement takes place in other respects, the water still 
continues to throw down a deposit on boiling ; for a long time a certain 
amount of albumen may be present, and under the microscope the sediment 
may continue to exhibit casts of tubes. In exceptional cases a permanent 
albuminuria may be left. In other instances, and these are probably more 
common than is usually supposed, the urine ceases to contain albumen and 
casts, and, indeed, with the exception of a low specific gravity, may pre- 
sent all the characters of health. Still the restoration cf the kidneys is not 
complete, and slight causes, such as a passing chill, may determine a return 
of all the acute symptoms which have been described. 

Dropsy without albuminuria is occasionally met with, and this not a 
mere anaemic dropsy. In some of these cases albuminuria has been 
present, but has disappeared. In others there has been no precedent 
albuminuria. 

Otorrhcea is a not uncommon complication of scarlatina. The discharge 
is often due to an inflammation of the external meatus, and is then, if at- 
tended to quickly, of little consequence. In many cases, however, it is a 
result of extension of the catarrh from the pharynx or nasal cavities through 
the Eustachian tube to the middle ear. It is then a more serious matter, 
for the tympanum soon becomes distended with its purulent contents. 
Destruction of the small bones of the tympanum usually follows, and the 
pus bursting through the tympanic membrane escapes by the external 
canal. The most serious consequences may arise from this complication, 
as will be described elsewhere (see Otitis, and its consequences). 

Abscesses may occur in the second or third week, or towards the close 
of the stage of desquamation. These collections of pus often delay con- 
valescence, and if they occur in the neck may be signs of serious import. 
In the cervical region they are nearly always the result of internal ulcera- 
tion. In every case, therefore, a careful examination of the throat should 
be made, and active measures are required to prevent any spreading of the 
destructive process in the pharynx. A not uncommon seat of abscess at 
this period is the submucous tissue at the back of the pharynx. This 
subject is elsewhere considered (see Retro-pharyngeal Abscess). 

Gangrene in various parts may occur. Cancrum oris occasionally fol- 
lows scarlet fever ; and gangrene of the vulva, the pharynx, the skin of the 
abdomen, and that over a suppurating gland may also be met with. Some- 
times, as may happen in the case of any fever of a low type which causes 
rapid reduction of the strength, scarlatina, if severe, is followed by hemor- 
rhagic purpura, with bleeding from several mucous surfaces. Even death 
may ensue as a consequence of the loss of blood. Nervous sequelae may 
be also met with. Infantile spinal paralysis has been known to occur ; and 
hemiplegia from plugging of the middle cerebral artery is seen in rare in- 
stances. 

In addition to the above complications, scarlatina is sometimes confused 
by the presence of other specific fevers. Diphtheria has been already men- 
tioned. Besides this disease, measles and small-pox have been severally 
known to attack the scarlatinous patient, and run their course at the same 
time with it. Typhoid fever and scarlatina have been also met with to- 
gether. 

There is a form of scarlatina which has been called latent. In this 
variety the symptoms are mild and ill-defined, and the rash pale and im- 
perfectly developed, or even quite absent. Indeed, the symptoms gener- 
ally are so little severe that the existence of the fever is often not suspected 



SCAELET FEYEK — DIAGNOSIS. 41 

until desquamation begins. It is then remembered that the child had 
complained of a passing sore throat, and had seemed languid and heavy for 
a day or two, but nothing more. In these mild cases the after-course of 
the illness is not always in harmony with its beginning. Indeed, in no 
case of scarlatina, however slight the early symptoms may appear to be, 
can we venture positively to predict a favourable course to the illness. 

It was long doubted if the form of scarlatina which occurs sometimes 
after surgical operations was a true scarlatina. The cases are usually of an 
inoffensive type and the general symptoms trifling. Still, a more severe 
form of the disease is occasionally met with. The rash appears a few days 
(two or three in most cases) after the operation, and may be almost the only 
symptom. There is often, however, high fever, but the soreness of throat 
is insignificant. Occasionally desquamation is absent. The healing of 
the wound is greatly retarded by the complication. That the disease is 
really scarlatina is shown by the fact that it protects the patient from the 
fever poison in after-life. 

Diagnosis. — In a typical case scarlet fever is a disease which can scarcely 
be mistaken. The initial vomiting and sore throat, with elevation of tem- 
perature and rapid pulse, followed on the second day by a uniform pink 
rash dotted thickly over with scarlet pun eta, is sufficiently characteristic. 
Unfortunately, many cases are not typical. The sore throat may be scarcely 
perceptible ; the rash may be pale, discrete, and partial ; and the tempera- 
ture on the morning of the second day may be little elevated above the nor- 
mal level. A child with chronic enlargement of the tonsils, who is subject to 
attacks of sore throat, is found to be feverish, to have some pain in deglu- 
tition, and to present a pale, ill-developed discrete rash limited to the neck, 
chest, abdomen, and thighs. In such a case it is allowable to feel some 
uncertainty as to the nature of the ailment. The appearance of the throat 
is, however, here of importance. The redness is not limited to the tonsils, 
bat extends over the soft palate, uvula, arches of the fauces, and often 
the back of the pharynx. The redness is uniform, but at its margin on 
the soft palate some punctiform redness may be seen ; or the redness may 
be punctiform in character on the soft palate, and uniform elsewhere. Such 
a throat, accompanied by vomiting, a hot skin, a quick pulse, and a white- 
coated tongue, is very suspicious of scarlet fever. Some forms of erythema 
imitate the rash of scarlatina very closely ; and if there is a history of a 
recent unwonted indulgence in diet, the illness may be easily attributed to 
this cause. If such a rash be accompanied by a normal temperature, scar- 
latina may be positively excluded. But it is important to remember that 
the increase of bodily heat may be very moderate. I have known the 
morning temperature on the second day to be only 99.5°, or one degree 
above the normal level, although the disease was a true scarlatina, which 
afterwards became better developed. A pulse of 140, however mild the 
other symptoms may be, should make us suspect the existence of the fever 
very strongly ; and in no case where the temperature reaches 100° or over 
should we venture positively to exclude the disease. An erythematous rash 
is seldom so widely diffused as is the eruption of scarlatina ; and in particu- 
lar is usually absent from the neck and limbs. It also spreads very irregu- 
larly. In all cases of doubt we should inquire about pains and stitrhess in 
the articulations, and examine the joints, especially those of the fingers, 
for signs of swelling. AVe should also feel for enlarged glands in the neck. 
Often these symptoms are present early, when the eruption is very partial 
and incomplete. 

When the rash is dark colored, discrete, and slightly elevated, it may 



42 DISEASE IN CHILDREN. 

be mistaken for measles ; but the absence of sneezing and lachrymation, 
and the presence of bright red injection of the throat, with an unusually- 
rapid pulse, should furnish a sufficient distinction. 

Roseola may be mistaken for scarlatina, but the rose eruption occurs in 
larger spots, and indeed more resembles measles than the disease we are 
considering. Moreover, in roseola there is little or no fever ; no swell- 
ing of the joints ; and the rapidity of the pulse is normal or only moderately 
increased. 

Scarlatina may be closely simulated by ague. Dr; Cheadle has described 
the cases of two children in whom the skin during the hot stage was covered 
with a bright red rash. This eruption, combined with a quick pulse and 
a high temperature, was very suggestive of scarlatina, and might easily 
have been mistaken for it. The distinguishing points are referred to else- 
where (see Ague). 

Sometimes in the mild anomalous cases of the disease desquamation 
may be long delayed, and the absence of peeling may be held to exclude 
scarlatina. In these cases we are directed by Sir William Jenner to examine 
the skin about the roots of the finger-nails for signs of scaling, as it may 
be discovered in this situation as early as a week or ten days from the 
cessation of the illness. 

Scarlet fever is hardly likely to be confounded with diphtheria, for the 
invasion and general symptoms of the two diseases are very different. It 
is important, however, not to overlook the possible intercurrence of diph- 
theria as a complication of the fever. If this unfortunate accident happen 
early, during the first week, there is usually an offensive discharge from 
the nostrils ; the voice often becomes hoarse ; and there are symptoms of 
great depression. If it occur at a later period, when the patient seems 
approaching convalescence, the fever returns ; the throat becomes again 
painful ; the glands of the neck enlarge and are tender ; there is a dis- 
charge from the nose ; and in most cases the larynx becomes quickly 
involved. According to Trousseau, scarlatina avoids the larynx, while 
diphtheria has a well-known tendency to attack the windpipe. The occur- 
rence of hoarseness, or the appearance of an offensive discharge from the 
nostrils, in any case of scarlatina, should cause us at once to make fresh 
examination of the throat ; and probably the appearance in the fauces of 
the dirty-white tough-looking membrane on the deep red swollen surface 
will at once prove the accuracy of our anticipations. 

Prognosis. — Scarlatina is a disease as to the course of which it is unwise 
to indulge in confident predictions ; for an attack which begins mildly 
enough may end in a very different manner. Some of the worst cases are 
those which begin in such a way. Scrofulous children are bad subjects for 
scarlet fever, and in them an attack of apparently mild type may be fol- 
lowed by a distressing series of complications. Not long ago I attended 
a young girl who had been subject for years to scrofulous disease of bone 
in various parts of the body. She was taken with scarlatina. The symp- 
toms were slight at first, and for a fortnight there was no cause for any- 
thing but satisfaction at the favourable progress of the illness. In the 
middle of the third week all this was changed. The patient first began to 
complain of rheumatic pains. She was then attacked in rapid succession 
by albuminous nephritis, peri- and endo-carditis, and double pleurisy. 
Ulcerative endocarditis then ensued, which led to cerebral embolism with 
left hemiplegia, and afterwards to renal embolism, with return of the albu- 
minuria and casts which had previously disappeared. The girl eventually 
died suddenly on the eighty-ninth day, apparently from clotting in the 



SCAELET FEVER — PROGNOSIS — TREATMENT. 43 

pulmonary artery. In cases such as this there may be positively no indica- 
tion that the hitherto benign course of the disease is to change so seriously 
for the worse. When, however, the fever has assumed a severe form in 
other children of the same family, we must always be prepared for some 
such catastrophe ; and until the disease is actually at an end we cannot 
put aside our apprehensions. 

Previous ill health from other causes than scrofula does not apparently 
modify the prognosis ; nor does early infancy influence unfavorably the 
course of the disease. The exact character the fever is to assume appears 
to depend upon the type of the epidemic and the constitutional peculiar- 
ities of the patient. 

The malignant forms of scarlet fever are almost invariably fatal, es- 
pecially those in which the nervous symptoms are violent. A mild noc- 
turnal delirium is not of unfavourable omen ; and slight wandering in the 
daytime, if there be no other symptom of nervous disturbance, need excite 
no anxiety ; but if the delirium is active and persistent, with violent agita- 
tion and sleeplessness passing rapidly into stupor and prostration, we can 
have little hope of a favourable issue. Convulsions occurring after the first 
day, especially if repeated, are very serious. No indication is to be derived 
from the colour of the rash, for a dark tint of the eruption is not necessarily 
an unfavourable sign. There is cause for great anxiety if the temperature 
rise continuously ; if the throat affection be severe ; if there be frequent 
and long-continued vomiting or copious dysenteric diarrhoea ; if nephritis 
appear early ; or if there be great diminution or suppression of the urinary 
secretion. Ursemic symptoms are not so severe in the child as they are in 
the adult. At least, according to my experience, it is not common for a 
child to die of ursemic poisoning, if judiciously treated. 

Treatment. — In cases where any member of a family is taken with 
scarlet fever, it is of importance to prevent the illness spreading to the 
others. Prompt isolation of the patient is of course to be insisted on ; 
and it is well, if the step can be conveniently adopted, to send the other 
children away from the neighbourhood 'of the sufferer. 

Various prophylactic measures have been recommended to arrest the 
disease in the incubative stage and prevent its further development. 
Belladonna, which was at one time largely employed with this object, has 
been now proved to be useless. It seems likely, however, that in arsenic 
we have an agent of greater value. It has been noticed that a person who 
is being treated with arsenic cannot be successfully vaccinated ; and it is 
possible that the drug may have a counteracting influence upon other 
forms of infective matter. Practitioners who have made use of the remedy 
with this object speak favourably of its prophylactic virtue. Dr. "VV. G. Wal- 
ford has given the drug largely to children who had been exposed to the 
infection of scarlatina, and states that out of nearly a hundred such cases 
in only two did the development of the fever follow, and both cases were 
extremely mild. He recommends the ordinary liq. arsenicalis (P.B.) in 
as large a dose as the age of the child will allow, with sulphurous acid 
( TTX xv. -xxx.), and a little syrup of poppy. The child should take the dose 
regularly three times a day at the first ; afterwards less frequently. 

When the disease actually declares itself, prophylactic measures must 
of course be laid aside. In a malady such as scarlatina, where the gen- 
eral symptoms are often violent, and the complications are various and 
may be severe, the therapeutic measures at our disposal are necessarily 
very numerous. Still, we must depend for a successful result more 
upon vigilant nursing than upon the actual administration of drugs ; 



44 DISEASE IN CHILDBED. 

although these, especially when complications occur, are often of sensible 
value. 

However mild the symptoms may be, the child should be kept in bed 
in a well-ventilated room, from which all carpets, curtains, rugs, cushions, 
and other woollen articles not required for the comfort of the patient have 
been previously removed. In order to prevent the spread of the disease, a 
sheet kept wet with a solution of carbolic acid (one part in forty parts of 
water) should be fastened so as to hang over the door-way ; and care 
should be taken to disinfect all excreta, soiled linen, etc., before they are 
removed from the room. The child may be allowed to drink as often as 
he desires of pure filtered water, but the quantity taken at each time of 
drinking must be limited. His diet should consist of milk, broth, light 
puddings, bread and butter, etc. The heat and irritation of the skin is 
greatly relieved by sponging the surface of the body several times a day 
with tepid water, and afterwards drying with a soft towel. This is a more 
pleasant operation than the inunction of fats, which is sometimes recom- 
mended, and is quite as serviceable to the patient. 

In an ordinary case little medicine is required ; but if the throat is 
painful, a draught of chlorate of potash may be ordered. Should the 
throat become much inflamed, and the cervical glands of the neck swell 
and be tender, the child should be made to suck ice, and hot applications 
(linseed-meal poultices, frequently renewed) should be applied to the 
neck ; or we may use the cold compress, which, becoming heated by con- 
tact with the skin, acts in the same way. Cold thus applied internally, 
while the outside of the throat is kept warm, often produces a rapid 
amelioration in the symptoms. If, however, the throat affection, instead 
of improving, becomes worse, aDcl ulceration is noticed, it will be neces- 
sary to apply some local application to the fauces. In such a case the 
throat having been carefully cleansed with a brush dipped in warm water, 
a solution of nitrate of silver (half a drachm to the ounce) should be 
applied freely to the whole of the ulcerated surface. Moreover, any 
special ulcer may be touched once with the solid caustic. The weaker 
application must be repeated every morning for three or four days ; and 
in the interval a solution of common salt in water (half an ounce to the 
pint) can be injected frequently into the fauces. It is very important in 
these cases to keep the throat clean inside, in order to remove quickly the 
poisonous secretions thrown out from the diseased surfaces ; and frequent 
syringing or gargling of the throat with a saline solution such as the 
above, which dissolves mucus and facilitates the separation of tenacious 
secretions, will be attended by marked benefit. If required to clean the 
mucous surfaces, the saline solution may be applied from time to time 
with a brush. In addition to these measures, disinfecting applications 
may be made use of; such as a weak solution (two per cent.) of carbolic 
acid, or a lotion composed of liq. sodse chlorinate ( tt[ xx. to the ounce of 
water). In these cases of severe sore throat it is advisable, as much for 
the sake of others as for the benefit of the patient, to keep the air of the 
room saturated with a solution of carbolic acid (one part in thirty of 
water) by Dr. E. J. Lee's steam draught inhaler, or some similar apparatus. 
The application of sulphurous acid to the throat, as recommended by the 
late Dr. Dewees, is also useful. This remedy should be used with an 
atomizer, and the acid, pure or diluted with an equal proportion of water, 
should be sprayed into the throat for a few minutes every two or three 
hours. 

If there be coryza, the saline solution may be injected into the nasal 



SCARLET FEVER — TREATMENT. 45 

fossae, or the nose may be syringed once a day with a weak solution of 
nitrate of silver (gr. v. to the ounce). 

Abscesses forming in the neck must be opened directly fluctuation is 
detected, and be afterwards well poulticed. If haemorrhage occur, the 
wound must be stuffed with lint soaked in perchloride of iron. A post- 
pharyngeal abscess must be also opened early with a large trocar and 
cannula. 

If otorrhcea be noticed, the meatus must be syringed out frequently 
during the day with warm water. If the tympanic membrane be perfect, 
the discharge proceeding only from the external canal, a syringeful of 
some mild astringent lotion should be injected each time after complete 
cleansing. Glycerine of tannin (one drachm to the ounce of water) or a 
weak solution of sulphate of zinc (gr. iij. to the ounce) answer well for this 
purpose. 

In the case of any of the above complications quinine in full doses 
(gr. iij. four times a day for a child five years old) should be given ; and 
a liberal diet should be allowed, due regard being had to the patient's 
powers of digestion. "When the temperature has fallen in scarlet fever 
the child should have meat once a day, an egg or a little bacon for his 
breakfast, and should take plenty of milk. As long as the water con- 
tinues clear we may be sure that he is not being overloaded with food ; 
but the appearance of a thick deposit of lithates should at once make us 
reconsider his dietary, and limit the quantity allowed at his meals. 

When the throat affection is severe, iron seems more beneficial than 
quinine, if administered energetically. For a child of this age fifteen to 
twenty drops of the pernitrate of iron should be given Avith glycerine and 
water every three or four hours. At the same time brandy-and-egg mixt- 
ure must be supplied in such quantities as seem desirable, according to 
the degree of prostration of the patient. In such cases children will take 
with benefit large quantities of the stimulant. Strong beef-tea, meat 
extract, etc., can also be given. 

If the disease be ushered in with obstinate vomiting, the symptom is 
best relieved by sucking ice. If diarrhoea occur, oxide of zinc (five grains 
for a child of five years old) or bismuth (gr. xv.) and chalk mixture should 
be resorted to. If at the beginning of the diarrhoea the motions are lumpy, 
a mild aperient, such as a dose of castor-oil or a rhubarb and soda powder, 
should be administered. 

In cases of malignant scarlet fever with violent nervous symptoms 
every kind of treatment will unfortunately be often found to fail. If the 
temperature be high, it must be reduced by cold bathing. The child 
may either be placed in a cool bath (temperature of 70° Fahr.), and kej)t 
there until his teeth begin to chatter ; or affusions with water of the same 
temperature may be practised, as recommended by Currie. I prefer the 
former method ; and there is no doubt that the immediate effect of the 
bath in lowering the pulse and temperature, dissipating the delirium, and 
relieving the agitation of the patient is very decided. When the temper- 
ature rises again and delirium returns the process must be repeated. 
Unfortunately, although there is temporary relief to the symptoms, the 
patient is seldom cured by this means, and usually falls after a time into 
a state of prostration and collapse, in whiqli he dies. A milder way of 
employing the same treatment is to wrap the child in a wetted sheet, and 
lay him upon a hard mattress, covering him inerety with a thin blanket 
thrown loosely over him. When he shivers he should be released and 
returned to his bed. The milder practice is suitable in the less severe 



46 DISEASE IN CHILDEEN. 

cases, and has a distinct effect in reducing the temperature. It must be 
remembered, however, with regard to this question of hyper-pyrexia, that 
children often bear high temperatures very well ; and it is difficult to lay 
down a broad rule as to the period at which it is necessary to intervene. 
It is better to be guided in this respect by the general symptoms than by 
the thermometer. If, as often happens, a child seems comfortable and 
composed, with a temperature of 105° or 106°, there is no occasion for any 
step more energetic than that of sponging the surface of the body with* 
warm water ; but if with a lower temperature (103° or 104°) he is deliri- 
ous, agitated, and distressed, the cold bath may be used with benefit. 
Wet packing is often useful in these cases ; but when thus enveloped in 
blankets the child's temperature must be carefully watched. If the skin 
be induced to act by this means, and the patient sweat profusely, the 
process is a beneficial one and the temperature will fall. If, on the 
other hand, the skin do not act, the effect of the packing is to cause a 
further increase in the pyrexia. Therefore, if the temperature be found 
to rise instead of falling, the blankets should be at once removed. In 
all these cases the bath, of whatever kind it be, should be supplemented 
by energetic stimulation in order to counteract the tendency to sudden 
collapse. 

If the child is from the first in a state of prostration, instead of the cold 
bath the hot mustard bath may be made use of ; but such cases are seldom 
benefited even temporarily. 

If rheumatic pains are complained of and the joints swell, these parts 
should be wrapped in cotton wool and covered with a firmly applied flannel 
bandage ; and Dover's powder should be given at night if the pains inter- 
fere with sleep. Attention must also be paid to the state of the bowels. 
Inflammation of the serous membranes must be treated upon ordinary 
principles. 

If albuminous nephritis occur, energetic treatment must be adopted at 
once. A mere trace of albumen, such as is often met with in cases of 
scarlatina, is of little consequence, and requires merely tonic treatment ; 
but the appearance of copious albumen in a smoky urine shows the pres- 
ence of acute Bright's disease, and is a very different matter. We should 
therefore at once proceed to sweat and purge the patient. There is, per- 
haps, no condition in which the beneficial influence of free purgation is 
more striking than in this complication. A child of five years old should 
take every night a dose of compound jalap powder (gr. xxx.-xl.) alone, or 
mixed with five grains of compound scammony powder. Enough should 
be given to produce two or three watery stools. In the daytime he should 
be wrapped in a sheet wrung out of tepid water and be then well packed 
in blankets ; taking at the same time a draught containing a solution of 
acetate of ammonia ( 3 j.) and antimonial wine (TTL xx.) to insure the free 
action of the skin. His diet should be simple. As long as there is any 
pyrexia no solid food should be allowed ; and the patient should have noth- 
ing but milk and broth with dry toast. Plenty of fluid is useful. If these 
measures be adopted, the albumen in the majority of cases will be found 
to disappear very quickly from the urine. Should it, however, persist, and 
the renal disorder seem to be passing into a chronic state, iron and ergot 
are indicated ; or three grains of the hydrate of chloral may be given (for 
a child of five years old) three times a day. In cases of ursemic convulsions 
purging and sweating carried out briskly are of equal service, and will 
usually quickly relieve the symptoms, especially if aided by a diuretic. The 
following is a serviceable form : 



SCARLET FEVER — TREATMENT. 47 

^ . Liq. ammonite acetatis TT|, xxx. 

Potassse acetatis gr. v. 

Sp. juniperis TT[ v. 

Sp. setheris nitrosi TT[ xx. 

Glycerini , TTj, xx. 

Aquam ad § ss. M. Ft. haustus. 
To be taken every four hours (for a child of five years old). 

A good diuretic for children is digitalis ; and the drug is well borne in 
early life. Five drops of the tincture given three times a day with an equal 
quantity of spirits of juniper may be employed. Jaborandi and its alkaloid 
pilocarpine are useful in these cases ; and can be given either by the 
mouth or by subcutaneous injection. The most convenient way of admin- 
istration is to make a fresh solution of the nitrate or hydrochlorate of 
pilocarpine in water of the strength of one grain to twenty-four minims. 
Of this solution three drops (one-eighth of a grain) can be injected sub- 
cutaneously, and is a suitable dose for a child of five years of age. Children 
bear this remedy well. If the solution is freshly made, copious sweating- 
follows the injection ; there is often profuse salivation ; and the secretion 
of urine is greatly augmented. The child should lie between blankets, so 
as to encourage the action of the skin. The dose may be repeated every 
day, if necessary. It often excites nausea and vomiting, but this is imma- 
terial. 

During the stage of desquamation measures should be taken to hasten 
the separation of the epithelium. The child should be oiled all over the 
body every night with carbolized oil (one part of the acid to twenty parts 
of olive-oil), and this should be well rubbed into the skin. Afterwards he 
should be thoroughly washed with soap in a warm bath. If this be carried 
out in a warm room, there is no fear of a chill. 

Even in mild cases the child should keep his bed for three weeks, and 
his room for a month at least, from the beginning of his illness ; and until 
the peeling has quite ceased the patient is unfit to associate with healthy 
persons. It must be remembered that desquamation may linger long about 
the wrists and ankles, the fingers and the toes ; and that a considerable 
time may elapse before the mucous membrane of the throat has completely 
recovered its normal state. When the child is finally pronounced to be 
well, it is advisable to send him to the sea-side for change of air before he 
resumes his ordinary habits and mode of life. 



CHAPTER IV. 

CHICKEN-POX. 

Chicken-pox or varicella is seldom seen except in young subjects. It is an 
infectious disorder which occurs generally in epidemics, and attacks by 
preference children aged from two to six years. At one time it was sup- 
posed to be a form of modified small-pox, but few are now of this opinion, 
for the evidence against it is overwhelming. Attempts have been made to 
impart the disease by inoculation, but without success. 

Symirtoms. — After a period of incubation, varying from seven to four- 
teen days, the child is noticed to be feverish, and within the next four-and- 
twenty hours a number of small rosy-red spots appear on the chest and 
over the body generally. These are slightly elevated, and number on the 
first day fifteen or twenty. In the course of a few hours — in any case by 
the next morning — the papule has changed into a vesicle or roundish bleb 
which is filled with clear serum. It has sometimes a very faint pink 
areola round its circumference. At the same time other papules have ap- 
peared, more numerous than on the first day. These in their turn become 
converted into clear blebs. In this way every morning finds a fresh crop 
of red spots, and of fresh blebs formed from the red spots of the previous 
day. The change from red spot to bleb may take place very quickly ; in 
fact, the rash has sometimes been described as vesicular from the first. 
In any case it is completed within ten or twelve hours of the appearance of 
the red papule. The spots appear in no regular order, but are scattered 
about all parts of the body and limbs, and may even be seen beneath the 
hair on the scalp. They are also occasionally found inside the mouth, 
on the soft palate, the inner side of the cheeks and lips, and at the sides 
of the tongue ; but when seated on mucous membrane the vesicle changes 
very rapidly to a small round ulcer. After appearing in successive crops 
for four or five days, fresh spots cease to be seen. The changes which 
each individual spot undergoes are as follows : — it increases in size for a 
day or two, and then its liquid contents, from clear, like pure water, be- 
come milky. Some burst and form crusts ; others present, after a day or 
two, a speck of scab on the summit, which to a hasty glance gives a false 
aj)pearance of umbilication ; the vesicle then dries up and leaves a thin 
crust, which falls off after a few days. No scar is left, as in variola, unless 
the child have irritated the skin by scratching ; in which case a shallow 
pit may be seen in the situation of the scab. It is difficult to prevent the 
child from scratching the spots, for the eruption is accompanied by con- 
siderable irritation. 

The amount of fever varies. At the beginning the temperature may 
rise as high as 102°, especially if the rash is slow to appear. After the first 
day or two, however, the pyrexia subsides considerably, and is seldom 
higher than 99.5° during the remainder of the illness. In some cases a 



CHICKEN-POX — DIAGNOSIS. 49 

slight exacerbation occurs with the maturation of the vesicles, but the 
temperature soon returns to the normal level. In the large majority of 
cases the constitutional disturbance is of the slightest. After the crusts 
have fallen the temperature sinks to a lower level than in health. 

The duration of the disorder is ten days or a fortnight, counting from 
the preliminary fever to the final fall of the crusts. Afterwards the child 
may be left in a weakly state for some time ; and delicate children may 
have the outbreak of serious disease determined by this apparently trifling 
complaint. Thus, I have known acute tuberculosis to succeed after a very 
short interval to an attack of chicken-pox. 

In exceptional cases the complaint is not over so quickly. Mr. J. 
Hutchinson was the first to draw attention to the gangrenous eruptions 
which sometimes occur in connection with the chicken-pox. This dan- 
gerous complication is not confined to weakly, ill-nourished children, al- 
though it is most common in them. It is no doubt connected with the 
curious tendency to spontaneous gangrene sometimes met with in chil- 
dren, and described in another chapter. 

In gangrenous varicella the vesicles, instead of drying up in the ordi- 
nary way, become black and get larger, so that a number of rounded black 
scabs, with a diameter of half an inch to an inch, are scattered over the 
surface of the body. If a scab be removed it is seen to cover a deep ulcer. 
Around it the skin is of a dusky red color. All the vesicles do not take on 
the gangrenous action, so that we find many varicellous scabs of ordinary 
appearance mixed up with the blackened crusts. The gangrenous process 
often penetrated deeply through the skin to the muscles, but under some 
of the scabs the ulceration is more shallow. These cases are very fatal. 
Mr. Warrington Haward has reported the case of a weakly baby of twelve 
months old, who weighed only six pounds and a half. This child was at- 
tacked with gangrenous varicella and died in a few days of pyaemia with 
secondary abscesses in the lungs. 

Diagnosis. — It is often a very difficult matter to distinguish between 
chicken-pox and modified small-pox. If the eruption follows very rapidly 
upon the first signs of fever, the disease is probably varicella, for in the 
case of varioloid the rash is usually preceded by two or three days of fever 
and malaise with vomiting ; and the pain in the back may be as intense as 
in the unmodified form of the disease. But there are many exceptions to 
this rule, for in some cases of varioloid the normal duration of the pre- 
emptive period is considerably shortened. Again, the spots in varioloid, 
as in variola, are grouped in threes and fives, while in varicella their distri- 
bution is more irregular. Then, the papule in varioloid is always shotty 
and hard. In varicella it is peculiarly soft, and always disappears on 
stretching the skin. If there be an elevation left after the fall of the scab, 
it is conclusive in favour of modified small-pox ; while a subnormal tem- 
perature occurring as early as the tenth day would point rather to varicella 
than to varioloid. According to Mr. Macuna, the varicellous vesicle is uni- 
locular, and can be emptied by one touch of a needle. The vesicle in 
small-pox, on the contrary, is always multilocular, and cannot be emptied 
by a single puncture. In case of doubt this difference will serve as a dis- 
tinguishing mark. 

It is important to be aware that a shallow pit or scar may be left here 
and there upon the skin after undoubted varicella. Pitting may occur 
in any case where, from the irritation of continued scratching, or from 
some constitutional peculiarity of the patient, ulceration of the skin has 
been set up in the site of a vesicle. 
3 



50 DISEASE IN CHILDEEN". 

Gangrenous varicella is distinguished by the history of the case, and the 
appearance of ordinary varicellous scabs mixed up with the blackened and 
gangrenous crusts. 

Treatment. — A child attacked by chicken-pox must be removed from 
other children, and prevented, if possible, from picking or scratching the 
spots. If there be much fever, he should be confined to bed and his 
bowels must be attended to. When the disease is at an end, the child will 
require a tonic, such as quinine or iron. If convenient, he may be taken 
to the sea-side ; and if there be any consumptive tendency in the family 
change of air during convalescence is not unimportant. 

In cases of gangrenous varicella little can be done beyond supporting 
the strength with good food suitable to the age and degree of feebleness of 
the patient, and giving the brandy-and-egg mixture as often as is required. 
If the gangrenous crusts are few in number, the scabs may be removed 
and the underlying ulcer filled with iodoform powder, as recommended by 
Parrot for gangrene of the vulva. 



CHAPTER V. 

COW-POX.— VACCINATION. 

The cow-pox, or vaccinia, is a disease with is natural to the milch cow, 
but never occurs in the human subject except as the result of direct vacci- 
nation. In the cow it appears on the teats and udder as isolated spots, 
which at first are papular, but afterwards pass through the vesicular and 
pustular stages, as in true small-pox. They scab on the thirteenth or four- 
teenth day, and fall off in the following week, leaving pits on the skin. 
This disease is now satisfactorily proved to be the real small-pox, altered in 
character and modified by its passage through the animal, but still capable, 
when conveyed to the human subject, of imparting as much protection as 
would be derived from a direct attack of the original disease. 

It is now a familiar story how Edward Jenner, then living as apprentice 
to a surgeon in Gloucestershire, determined to investigate the truth of a 
belief, current in the neighbourhood, that milkers who had become inoc- 
ulated with cow-pox in the pursuit of their calling, were no longer suscep- 
tible to the contagion of small-pox ; and how, by careful observation and 
experiment, he succeeded in establishing the important conclusions — that 
cow-pox communicated by inoculation to the human subject did actually 
confer immunity from small-pox ; also that the disease, so engrafted, might 
be transmitted indefinitely from person to person without any abatement of 
its protective power. Since Jenner's time the practice of vaccination has 
become universal, and to this great discovery we owe it that small-pox, as 
it used to be, with all its dreadful consequences, is almost unknown in the 
present day. 

Symptoms and Course. — After the introduction of the lymph under the 
skin of a child previously unvaccinated the following is the course of the 
induced disorder. For two days no change takes place, but at the end of 
the second day, or beginning of the third, a small elevated papule is seen 
at the site of the puncture. This enlarges, and by the fifth or sixth day 
has become a circular raised pearly-gray vesicle, with- a depression in the 
centre. The vesicle grows, and by the eighth day is fully developed. It is 
then seen as a flattened, round, gray-colored vesicle, still depressed in the 
centre and filled with a colorless lymph. It does not remain stationary, 
but begins at once to lose its transparency ; a red areola forms round its 
base and quickly spreads, so that by the tenth day the vesicle is found 
seated on a hardened red base, with the red areola extending for one or 
more inches over the skin around. The vesicle has now become a pustule 
with purulent contents, and around it the subcutaneous tissue is hard and 
swollen. After the tenth day the areola gradually fades ; the fluid contents 
of the pustule undergo absorption ; and by the fourteenth or fifteenth day 
a scab has formed, w^hich gradually loosens and becomes detached. The 
crust usually falls in about three weeks from the time of puncture, and in 
its place is seen a round sunken scar pitted with little depressions. 



52 DISEASE IN CHILDREN. 

The disease is at first purely local, but afterwards becomes general. 
According to Dr. Squire a continuous rise of temperature begins on the 
fourth or fifth day. This suddenly increases on the eighth day, and as 
suddenly falls a day or two afterwards, when the areola has ceased to ex- 
tend itself. The maturation of the vesicle is also accompanied by other 
signs, showing that the disease has begun to affect the system. The child 
is restless and uneasy ; there is some digestive disturbance ; and the 
lymphatic glands in the armpit become tender. Sometimes a roseolous 
red rash makes its appearance on the affected limb, and may extend to 
the other extremities. This rash may become papular or even vesicular. 

The above is the course of the disease when the inoculating lymph is 
taken from another child. Some practitioners prefer to use lymph ob- 
tained directly from the cow. But with "primary" lymph there is more 
difficulty in operating successfully; and when the vaccination takes effect, 
the constitutional s} r mptoms are more severe. There is also another dif- 
ference. "With such lymph the whole process is retarded. The papule 
does not appear until a week or even a longer time has elapsed, and the 
areola does not become complete until the eleventh or even the fourteenth 
day. The swelling and hardness around the pustule are greater, and the 
secondary rashes are more frequently seen. The scabbing stage is also 
prolonged, and the crust may not fall for a month or six weeks from the 
day of operation. 

Even when humanized lymph is made use of, the process is occa- 
sionally retarded. This may be the case when dried lymph is employed, 
and is invariably seen if the patient happen to be incubating measles or 
scarlatina. Sometimes, too, it appears to be owing to a constitutional 
peculiarity. Mere retardation does not, however, affect the value of the 
result if the development of the induced disease be normal. Instead of 
being retarded, the process may be accelerated ; but this, again, is imma- 
terial, provided the course of the pock be regular. If, however, for what- 
ever reason, the course of the disease be not regular, and the pock be in 
any way incomplete, the result must be looked upon as unsatisfactory, 
and the protection so afforded cannot be relied upon. Vaccination is apt 
to be rendered irregular by the presence of acute febrile disease ; of 
diarrhoea ; or of certain skin diseases, especially herpes, eczema, intertrigo, 
lichen, and strophulus. ' In all such cases, directly the child's health is 
restored, the operation should be repeated. Unfortunately it will then 
often fail ; for after a spurious vaccination the child may be left— tem- 
porarily, at least — insusceptible to the action of the lymph. 

In cases of re vaccination the result is often irregular. The whole 
process is then hurried. The papule appears early ; the vesicle is fully 
developed by the fifth or sixth day ; and then at once declines. On the 
eighth day a scab forms, and becomes detached a day or two later ; so 
that in less than a fortnight the disease has run through all its stages. 
With this, the constitutional symptoms are more severe, and the itching 
and local discomfort greater, than in cases where the inoculation is prac- 
tised for the first time. 

Protective Value of Vaccination. — Effectually performed, vaccination is, 
in the majority of cases, a permanent protection against small-pox ; that is 
to say, the protection afforded by it is as great as that furnished by an 
actual attack of variola. Jenner himself never claimed that it would do 
more than this. As a rule, an individual who has been successfully and 
sufficiently vaccinated is either insusceptible to the contagion of small- 
pox, or is capable of taking the disease only in a mild and modified form. 



COW-POX — VACCINATION. 53 

It is, then, very important to ascertain what constitutes an efficient vac- 
cination. This question has been answered by Dr. Marson, who found, as 
a result of thirty years' observation of small-pox cases in the London Fever 
Hospital, that while in unvaccinated persons the mortality was as high as 
37 per cent., the percentage gradually diminished in exact proportion to 
the number and completeness of the vaccination cicatrices ; so that in 
persons who could show four or more well-marked scars the mortality 
was only .55 per cent. It should therefore be the aim of every vaccinator 
to produce four or five genuine well-developed vesicles upon the arm of 
the patient. With less than this number the vaccination, although it may 
be successful, cannot be considered to be sufficient, nor the protection as 
complete as it can be made. As a further precaution it is usual to re- 
vaccinate the individual after he has attained the age of puberty. Should 
this be unsuccessful, it is advisable to repeat the operation if at any time 
the person become liable to be exposed to the contagion of small-pox ; 
especially if upon examination of the arms he is seen to bear only imper- 
fect evidence of a former vaccination. The protective power of vaccina- 
tion is well seen in the following figures, kindly supplied me by my 
friend Dr. Twining. The cases were under the care of Dr. Gay ton, of the 
Homerton Small-pox Hospital. Between 1871 and 1878, 1,574 children 
came under observation, suffering from small-pox. Of these, 211 had been 
efficiently vaccinated, and one of them died : 396 had been imperfectly 
vaccinated, and of these 39 died : 179 were said to have been vacci- 
nated, but bore no marks ; of these 46 died : 788 were known never to have 
been vaccinated, and of these 385 died. Taking the last two groups to- 
gether, the mortality in unvaccinated children was 44 per cent, under ten 
years of age. 

Method of Vaccinating. — The lymph used should be taken from the arm 
of a healthy child at some time between the sixth and eighth day of vesica- 
tion, while the vesicle still retains its purity and transparency. After the 
eighth day it should not be used. The child, the subject of the operation, 
should be in good health. If he be poorly, especially if he be feverish, or 
be suffering from some skin eruption, the operation should be postponed. 
It was Jenner's own direction to sweep away all eruptions before inserting 
the lymph. This rule is a very important one, for although the vaccina- 
tion may possibly take effect, it is more likely that it will fail, and a spurious 
vaccination may render the child's system insusceptible to the vaccine 
lymph without affording the desired protection against sruall-pox. Many 
methods of inserting the lymph are now in use. The simplest, and perhaps 
the best, is to make three separate punctures on each arm, inserting the 
point of a perfectly clean lancet, moistened with fresh lymph, sufficiently 
deeply to draw a little blood. In making the punctures the skin is stretched 
between the finger and thumb, and the point of the lancet is inclined down- 
wards, so as to enter the skin obliquely. If fresh lymph cannot be obtained 
from the arm of another child, lymph stored in capillary tubes, or dried on 
ivory points, may be used. The dry points must be first well moistened 
with water, and then inserted into the punctures made by the lancet. As 
many should be used as there are punctures made ; and the points should 
be pressed down into the little wounds and allowed to remain for a minute. 
On being withdrawn, they should be pressed against the sides of the punc- 
ture, so as to insure the lymph being left in the skin. 

Occasional Sequela? of Vaccination. — Sometimes erysipelas has been set 
up by vaccination, and even pyaemia has been known to follow, and cause 
the death of the child. These unfortunate consequences are not to be 



54 



DISEASE IN CHILDREN. 



attributed necessarily to any carelessness or awkwardness on the part of 
the operator, nor to any impurity in the lymph employed. They are due 
to the constitutional state of the child at the time of the operation — a state 
in which the puncture of the lancet is followed by these untoward accidents 
just as any other trifling operation might be followed by them. A roseolous 
and papular rash has been already referred to as sometimes following 
the maturation of the pustule ; but other rashes, such as eczema and the 
various skin eruptions to which children are liable, may be seen after 
vaccination. These rashes are always attributed by parents to the insertion 
of the vaccine lymph. In some cases vaccination may have been indirectly 
a cause of the skin affection by lowering the child's general health — a 
result which in childhood is apt to follow any feverish attack ; but often 
the occurrence of the eruption at a short interval after the vaccination is a 
mere coincidence, and is owing to an entirely different cause. In out- 
patients' rooms of hospitals it is not uncommon to find even scabies attrib- 
uted to a recent vaccination. 

Syphilis and scrofula are said to have been conveyed from child to child 
by the vaccine lymph. With regard to the first of these diseases, it was 
long denied that such transmission was possible. Experiments were made, 
and in France children were deliberately vaccinated with lymph taken 
from other children suffering from inherited syphilis ; but in no case was 
syphilis found to be communicated by the operation. Many cases, how- 
ever, have been since published which leave no doubt that communication 
of the syphilitic virus may take place by this means. The old notion that 
the fact of a vaccine vesicle undergoing its normal development and pre- 
senting its normal appearance is distinct proof that the lymph within it is 
uncontaminated by foreign virus, appears to be a correct one. In syphilitic 
children vesicles may assume this appearance, and are then incapable of 
transmitting any disease other than the cow-pox. If, however, in taking 
lymph from these vesicles, the puncture be made carelessly, and, with the 
lymph, some of the blood be taken up by the point of the lancet and inocu- 
lated into a healthy child, syphilis may follow. No doubt many of the 
cases in which a syphilitic rash has followed vaccination have occurred in 
children the subjects of inherited syphilis, in whom the febrile movement 
induced by the process of vaccination has determined the outbreak of an 
already existing disorder. So also in scrofulous children, a little derange- 
ment of the health will often rouse up the latent cachexia, which but for 
this might have remained dormant a little longer. 



CHAPTEE VI. 

SMALL-POX. 

Owing to tlie beneficent discovery of Edward Jenner the full terrors of 
small-pox as it used to prevail can now hardly be realized. In unvacci- 
nated persons, and those upon whom the operation has been performed im- 
perfectly, the disease may still rage with all its natural violence, but in or- 
dinary cases the form of the disease met with is the milder variety which 
is called varioloid. It is the same disease as variola, although modified 
more or less by occurring in a subject partially protected by vaccination. 

Small-pox is one of the most infectious of the acute specific fevers, and in 
this respect the modified form is as dangerous as true variola. The patient 
seems to be capable of communicating the disease even before the eruption 
appears, probably, therefore, from the very beginning of the early fever. 
He also continues to be a source of danger to others as long as any par- 
ticle of scale or scab remains attached to his body after the subsidence of 
the disease. One attack usually protects against a second, but it is far 
from uncommon for a person to take the fever two or even three times. 

Morbid Anatomy. — As in most of the infectious fevers, the blood in 
fatal cases is dark and coagulates imperfectly ; fibrinous clots are often 
found in the right ventricle of the heart ; and in very severe cases hemor- 
rhagic extravasations are scattered about in the loose tissue beneath the 
serous and mucous membranes. Internal organs, such as the heart, liver, 
and spleen, are either pale, flabby, and soft, or deeply congested. The 
mucous membranes, especially of the air-passages, are intensely hypersemic, 
and are thickened, softened, and sometimes ulcerated. Their epithelium is 
partially separated, and their surface is covered with a brown tenacious 
mucus. Tne same condition may be found in the mucous membrane of 
the nasal fossge, the mouth, fauces, and gullet. In all of these parts small 
excoriations may be noticed. They are small round spots on the mucous 
surface, either covered by a whitish false membrane or presenting a round 
point of superficial ulceration. These are probably due to an eruption on 
the mucous membrane of a like nature to that which takes place upon the 
skin. No such appearances are seen upon the gastro-intestinal mucous 
membrane, but the intestinal follicles and the glands of Peyer's patches are 
large and projecting. The lungs are often intensely congested, and are 
sometimes the seat of pneumonia. Moreover, the pleura of one side may be 
filled with sero-purulent fluid. 

In the skin the morbid changes are as follows : A punctiform hyper- 
emia takes place at various spots which extends through the cutis to the 
rete mucosum. The cells of this part swell and proliferate, so that a solid 
sharply defined nodule is formed at the inflamed spot. Next, the epider- 
mis is raised up by fluid exudation into a vesicle. If this be formed round 
a hair-follicle or sweat-gland, it is umbilicated in consequence of the sum- 
mit being held down by the duct. The vesicle is multilocular, for its in- 



56 DISEASE IN CHILDREN. 

terior is divided into several chambers by delicate partitions. These are 
not fibrinous, as used to be thought, but are formed by compression of 
the altered cells by the effused fluid. They disappear, as well as the um- 
bilication, when the process of maturation is complete. The vesicular fluid 
contains many leucocytes and some red blood corpuscles. As the prolif- 
eration of the cells of the rete mucosum continues, the fluid becomes 
purulent and the vesicle is changed into a pustule. The true skin is some- 
times destroyed by this suppurative process to some depth, and there is a 
depressed permanent scar then left after the fall of the scab. 

Symptoms. — The period of incubation of small-pox when contracted by 
infection is, according to Mr. Marson, thirteen times twenty-four hours, 
i.e., twelve whole days and parts of two others. If the disease is produced 
by inoculation, the period is shortened to seven or eight days. During 
this stage there are no symptoms in ordinary cases, although a certain 
amount of irritability and peevishness is sometimes noticed, not usual with 
the child and indicative of uneasiness ; but no definite symptoms can be 
observed. On the fourteenth day the first decided indication of the illness 
appears and the stage of invasion begins. Chilliness with a rise of tem- 
perature, sickness often distressing, and severe paius in the back and loins, 
sometimes in the limbs as well, are the characteristic features of this 
period. The pain in the back may be associated with temporary para- 
plegia, and is often combined in children with incontinence of urine and 
fasces. Other symptoms are : thirst, loss of appetite, a coated tongue, 
grinding of teeth, frontal headache, and constipation or diarrhoea. A 
severe amount of nervous disturbance is often seen, and the child may be 
thrown into violent and repeated convulsions with intermediate delirium 
and stupor. The violence and frequency of these attacks are not to be re- 
lied upon as an index of the severity of the illness which is to follow, as 
they are probably dependent less upon the intensity of the variolous poison 
than upon the natural nervous sensibility of the child. A little girl, aged 
six years, began to have fits on November 27th ; they continued until the 
29th. Between the convulsive seizures the child was drowsy and stupid, 
and often vomited. On the 29th the eruption appeared. The nervous 
symptoms then ceased, and the disease ran a particularly favourable course. 

The period of invasion lasts for forty- eight hours. During all this 
time the initial symptoms persist and the temperature continues to rise. 
The pyrexia is not always great at this stage. A boy, aged eleven years, 
a patient in the East London Childrens' Hospital, suffering from heart 
disease and pleurisy, who had not been previously feverish, was found one 
morning to have a temperature of 101. 6 \ The next morning it was 99°, 
and in the evening 102°. On the following morning (the third day) the 
thermometer marked 102.2°, and the eruption appeared. In many cases, 
however, the pyrexia is greater, and the temperature may reach 105° or 
higher. In the case of the little girl before referred to it was 103.6° on 
the morning of the second day. Occasionally during this stage a roseo- 
lous eruption, very like the rash of scarlatina, appears upon the skin. 
This is most common in cases of modified small-pox. It is right to say 
that the symptoms of the pre-eruptive stage are not always seen in this 
marked form. Dr. Twining of the Homerton Fever Hospital informs me 
that of the children who are admitted into that institution suffering from 
variola, many have complained merely of malaise, headache, or sickness ; 
and in not a few cases the first symptom noticed was the rash of the 
disease. 

The eruptive stage begins on the third day. In exceptional cases — 



SMALL-POX — THE EEUPTIYE STAGE. 57 

usually those of a malignant character — the rash may appear on the second 
day. Occasionally it does not show itself until the fourth. These excep- 
tions are found in all the eruptive fevers. The special small-pox eruption 
begins as small red papules scattered more or less thickly over the surface. 
They are first noticed on the chin, nose, or forehead, and then quickly 
sjDread to the whole face. They are next seen on the wrists, and in the 
course of the following twenty-four or forty-eight hours spread gradually 
to the chest, the arms, the trunk, and the lower limbs. The spots are not 
sprinkled irregularly over the surface, but may be noticed to group them- 
selves in threes and fives, often arranged in a semicircle. Sometimes 
when two of these crescents come together, they may by their junction 
complete the circle. The spots are set more thickly on the face than on 
the body, and as they appear earliest in this situation, they run through all 
their stages, and scab earlier here than on the trunk and limbs. The 
papule is hard, and gives to the finger the sensation of a small shot em- 
bedded in the skin. All are not, however, of equal firmness. Some have 
much more of a shotty character than others. Between the papules the 
skin is of normal colour and appearance ; but if the spots are set very 
closely together, there may be a general redness and granular look of the 
face without any intervening normal tint of the skin being visible. 

At the same time that the papules appear on the skin, spots may be 
also seen, if looked for, on the inside of the cheeks and lips, on the inside 
of the nose, and sometimes even on the conjunctiva?. At first, as they 
cause little discomfort, these are scarcely complained of ; but after a day 
or two they produce salivation, and pain in swallowing, and, if the air- 
passages are similarly affected, hoarseness and cough. There is also some 
snuffling, and the eyes are red and watery. Later, when the rash is ap- 
pearing on the lower limbs, the mucous membrane of the vagina, or 
urethra and prepuce, also become the seat of eruption. 

The changes which occur in the rash are as follows : The papule en- 
larges, becoming a flat-topped nodule, and in the course of the second or 
third day (fifth or sixth of the disease) changes into a vesicle. This 
change takes place, as has been said, earlier on the face than on the body 
or limbs ; and, indeed, while the papules are coming out on the lower 
extremities, those on the face are already changing into vesicles. The 
vesicle is broad, flat-topped, and umbihcated. Its contents are opaque, 
and at first whitish in colour ; but by the sixth day (eighth of the disease) 
have become distinctly purulent, a deep red areola has formed round the 
pock, and the subjacent skin is swollen by inflammatory effusion. The 
spot is now a pustule seated on a thickened base. From the eighth to 
the eleventh day the pock enlarges ; and the union of neighbouring areolae 
and the thickened bases of the pustules produces a general redness and 
swelling which completely obliterates all distinctive character in the feat- 
ures of the patient, and causes a distressing tension and smarting irrita- 
tion of the skin which is greatly complained of. There niay be also extreme 
tenderness, so that the slightest touch is painful. The eyes are often closed 
by the swelling, and the lids are glued together by the vitiated secretions 
from the Meibomian glands ; the nose is stopped up ; the secretion of 
saliva is profuse ; and swallowing is very difficult and painful. The voice, 
too, is hoarse and the cough distressing. Often the eyes are inflamed, 
painful, and very sensitive to light. The process of maturing of the 
pustules (stage of maturation) lasts from the sixth to the ninth day (eighth 
to the eleventh of the disease) on the face ; on the lower limbs it begins 
and ends a day or two later. Consequently, the vaginal and urethral 



58 DISEASE IN CHILDKEN. 

rashes and the distress they produce are at their height when the faucial 
and laryngeal mucous membranes have begun to improve. On these and 
the other mucous surfaces the eruption does not pass beyond the vesicular 
stage, but is accompanied by considerable redness and swelling of the 
membrane. While the pustules are maturing on the skin, the suppurat- 
ing spots give out a peculiar and unpleasant odor, which is, however, char- 
acteristic of the disease. 

The eruptive stage lasts about eight days — from the third to the 
eleventh of the illness. The apj^earance of the rash is usually the signal 
for a remission in the fever, and in the symptoms of general constitutional 
disturbance ; but there is seldom a notable fall in the temperature until 
the eruption is fully out. If the pyrexia remain high after the papular 
stage is completed, the disease is severe and unmodified, or some compli- 
cation is present. In confluent small-pox the remission is very imperfect 
and transient, the reduction of temperature is inconsiderable ; and whereas 
in a mild discrete case the patient feels almost well at this time, in the 
severer form of the disease the alleviation to the distress is much less 
complete, and even at this early stage of the illness photophobia, saliva- 
tion, pain in deglutition, and hoarse cough may be the source of great 
discomfort. In an ordinary case of discrete small-pox when the eruption 
is fully out, the temperature, although still above the normal level, is com- 
paratively little raised ; nervous symptoms are no longer noticed ; and 
except for the local inconvenience of the state of the skin, the condition of 
the patient is greatly improved. 

When the pustular stage is reached and the process of maturation be- 
gins (about the sixth day of the rash, eighth or ninth of the disease), the 
temperature rises again, and what is called " the secondary fever " begins. 
The intensity of this later pyrexia varies according to the severity of the 
attack. In mild cases it may be slight or even absent ; but in severe cases, 
especially in the confluent form of the fever, the temperature rises to a 
higher level, perhaps, than in the earlier stage ; the child is stupid or de- 
lirious, and often wakeful at night ; his tongue is furred and often dry ; his 
pulse gets quick and feeble ; his weakness is great ; and tremors, subsultus 
tendinum, with other symptoms of prostration, may be noticed. In not a 
few cases the disease has ended in death before the period of secondary 
fever is reached. In the severe cases, if the patient do not die at this 
time from the violence of the disease, he is very apt to succumb to an in- 
flammatory complication. 

The secondary fever lasts until the maturation of the pustules is com- 
pleted on the eleventh or twelfth day of the illness. The disease then en- 
ters into its latest period, that of desiccation and decline. In the course 
of two or three days the pustules discharge their contents ; the redness 
and swelling of the skin subside ; the odor from the child's body becomes 
extremely offensive ; and yellowish-brown, thick scabs form from caking 
of the purulent secretion. Nearly at the same time — unless some febrile 
complication arise — the pyrexia begins to subside and the tongue to clean ; 
the painful symptoms connected with the mucous membranes disappear in 
the order in which they occurred ; the pulse slackens and the appetite im- 
proves. The falling of the crusts is accompanied by some itching of the 
skin. It takes place earlier in some parts than in others, and is delayed in 
proportion to the amount of ulceration which is present in the cutis. If 
this be great, the scabs become very thick and horny, and remain attached 
for a long time. Sometimes successive crops of scab are thrown off before 
the underlying surface has become healthy. The size of the fallen crusts 



SMALL-POX — COMPLICATIONS. 59 

is also subject to variety. If the pustules have been thickly set, the edges 
of the neighbouring scabs may unite, so that large pieces of dark brown, 
horny crust become detached at the same time. The separation of the 
scabs is often very slow on the scalp in children ; and often new crusts 
continue to form after old ones have been removed with wearisome persist- 
ence. When the crusts have all fallen, the surface is left mottled with 
slightly elevated red spots, which eventually either disappear leaving no 
trace, or, if there has been ulceration, change into depressed white deep 
scars with inverted edges and an irregular floor. 

Complications. — In severe cases, even if the child survive until the pe- 
riod of the secondary fever, he is very apt at that time to be carried off 
by some one of the many complications which are liable to come on in the 
third or fourth week of the illness. The severe forms of small-pox, espe- 
cially the confluent variety, are most commonly attended by these acci- 
dents ; but they may also follow the milder forms of the disease. 

Boils are very frequently seen ; and the intense inflammation of the 
cutis which occurs in the severer attacks may pass into partial mortification 
of the tissues. Spots of gangrene are thus formed in the skin, and the 
same thing may be observed in the genitals. If a scrofulous child who 
suffers from vaginitis be attacked by small-pox, there is great danger lest 
gangrene of the vulva supervene. Such cases, it need not be said, are 
very dangerous. 

Abscesses and acute cellulitis may occur. Deep-seated collections of 
matter often form and may reach a considerable size. They are slow to 
heal. Sometimes the joints are the seat of suppuration. 

Erysipelas and pyaemia are common in small-pox hospitals — less com- 
mon in private houses, although they may be met with anywhere when the 
disease is confluent or very severe. The latter of the two sometimes suc- 
ceeds to the former and is very fatal. 

Otitis with suppuration in the middle ear is a not uncommon complica- 
tion. . The results which may follow from this distressing affliction are 
described elsewhere. 

In all bad cases of small-pox there is conjunctivitis, which may come 
on as early as the fifth or sixth day of the eruption. If swelling prevents 
the lids from being opened, conjunctivitis may be suspected if the child 
complaiD of pain in the eyeball, increased by movement of the eye, 
and of a feeling of dirt beneath the lid. In very rare instances we 
meet with a development of small pustules on the mucous membrane of 
the eye ; but slight ophthalmia of this kind as a rule is easily overcome. 
The severe inflammation which leads to ulceration of the cornea and de- 
struction of the eyeball sets in about the beginning of the third week (on 
the fourteenth day, according to Mr. Marson). An ulcer appears on the 
margin of the cornea, sometimes on both sides of the cornea at the same 
time. The various layers are quickly penetrated ; the aqueous humour es- 
capes ; and often the lens and vitreous humour are discharged. The process 
is generally very rapid, and may be accompanied by no pain to the child. 
Sometimes, instead of ulceration, general sloughing of the eyeball may occur. 

To some form of chest affection many deaths in small-pox are owing. 
Pleurisy is common and very fatal. Pneumonia may begin insidiously, 
and is also a very serious complication. Bronchitis is sometimes a cause 
of death ; and, according to RiUiet and Barthez, pulmonary oedema is occa- 
sionally met with. Besides these, .peri- and endo-carditis may supervene, 
and it is stated on the authority of Desnos and Huchard that acute fatty 
degeneration of the walls of the heart may be a cause of sudden death. 



60 DISEASE IN CHILDREN". 

The laryngeal symptoms during the period of secondary fever may be 
complicated by oedema of the larynx. This, however, is seldom seen 
except in cases of confluent small-pox. In other instances a severe laryn- 
gitis may be set up, leading to ulceration of mucous membrane, perichon- 
dritis, and necrosis of cartilage with consequent chronic aphonia. Laryn- 
gitis may be one of the earliest complications, and is sometimes seen on the 
tenth or eleventh day. 

In the case of any of these complications the fever is high and the child, 
who is barely entering upon convalescence after an exhausting disease, is 
in a state of great weakness, which is instantly aggravated by the presence 
of the intercurrent lesion. So that, if the patient do not succumb to this 
new danger, his illness is seriously protracted and convalescence propor- 
tionately delayed. 

Varieties. — Many varieties of small-pox have been described ; but for 
practical purposes it will be sufficient to remember the special forms of 
Discrete, Confluent, and Malignant small-pox, and the modified form found 
in efficiently vaccinated persons which is called varioloid. 

In the discrete variety the spots are separated from one another by 
healthy skin of normal tint. The general symptoms are usually milder, 
and the fever less high, especially the secondary pyrexia, which is much 
less severe. Still, even in this form serious complications may arise, and 
when death occurs, it is usually owing — unless the patient be a young in- 
fant — to one of these secondary lesions. 

The confluent form is attended by a very high mortality. From 
the records of the London Fever Hospital it appears that of those at- 
tacked by this variety fifty per cent. die. In children probably the 
proportion of deaths would be much greater. The danger consists not 
only in the severity of the eruption, but also in the intensity of the general 
symptoms. The initial fever is very violent, and is often accompanied by 
high delirium ; there is little remission in the pyrexia when the develop- 
ment of the rash is completed ; tremors and signs of profound nervous de- 
pression come on early ; the swelling and inflammation of the mucous 
membranes produce great distress ; and the secondary fever is very vio- 
lent. If the child survive to the third week, which rarely happens, a seri- 
ous complication usually occurs, and this in his exhausted state proves 
rapidly fatal. 

These cases, on account of their severity and fatality in young subjects, 
might be justly described as malignant. The term is, however, usually 
confined to cases in which the nervous symptoms are overwhelming, and 
the child dies rapidly from blood-poisoning in a state of profound depres- 
sion and coma ; or to cases where the disease assumes a hemorrhagic 
character. In this hemorrhagic form bleeding occurs from all the mucous 
membranes — the nose, the mouth, the air-passages, and the bowels. The 
urine is smoky or red with blood ; the eruption is dark, and mixed up with 
petechise or larger subcutaneous extravasations ; and the fluid in the vesicles 
is tinged with blood. The general symptoms are severe, the prostration 
great, and death takes place after a few days. My friend, Dr. Twining, 
has described to me a variety of the malignant form of small-pox which has 
often come under his notice at the Homerton Fever Hospital. In this the 
child appears overwhelmed by the violence of the disease. He lies in a 
state of stupor, and has no true variolous rash nor any of the ordinary 
symptoms of the illness. On inspection of the skin a number of deep 
purple, almost black, spots are seen. These are well defined, and are more 
or less circular in shape. They vary in size from a rape to a millet seed, 



SMALL-POX — VARIETIES — DIAGNOSIS. 61 

and are twenty or thirty in number. Mixed up with them are larger 
patches of subcutaneous extravasation, like bruises. These patients have 
a very offensive smell, as if putrefaction had begun before death, and sur- 
vive but a few hours. 

Varioloid, the modified form of the disease, is usually a mild com- 
plaint. The early symptoms are the same as in true small-pox, and may 
even be of some severity. A child may have high fever, much pain in 
the back, repeated vomiting, and be convulsed ; but the after-course of 
the disease is usually benign, and in particular the secondary fever is slight 
or completely absent. Often, the rash is preceded by a roseolous eruption. 
The proper rash of varioloid, which comes out at the usual time, is in most 
cases comparatively thinly scattered over the surface, and the spots are 
very rarely set sufficiently closely to be confluent, even on the face. As in 
variola, the mucous membranes are affected ; and salivation, difficult deglu- 
tition, snuffling, hoarseness, and cough are common symptoms. The spots 
run through their stages more quickly than in the unmodified form, and 
the stage of desiccation usually begins on the fifth or sixth day of the erup- 
tion. The stage of maturation is also less severe ; there is less swelling 
and redness of the skin ; and pyrexia is slight or absent. Generally the 
pustules, instead of rupturing and discharging their contents, dry up, so 
that the pock gradually changes into a thin brown scab, which falls off in a 
few days. There is besides little or no ulceration of the skin, and conse- 
quently no pitting is left after the subsidence of the disease, except here 
and there where the inflammation had proceeded farther than usual, Lastly, 
in varioloid complications are rare, and the disease is usually at an end in 
a fortnight. 

Diagnosis. — Before the eruption appears the diagnosis of small-pox is 
difficult in children, for fever and vomiting usher in many of their acute 
diseases, and pain in the back is not always complained of. In young- 
children the existence of the spinal pain can seldom be ascertained ; but if 
a child, in addition to vomiting and fever, loses control over his sphincters, 
we may suspect small-pox, for such incontinence is not a common symptom, 
and points to some special condition not present at the onset of an ordinary 
acute illness. In sraall-pox it may be the consequence of the spinal irri- 
tation. 

When the eruption first appears on the face it is often mistaken for 
measles. The colour is very similar ; and the early papules may be easily 
confounded with that form of measles rash in which the spots are more 
than usually elevated above the surface. On closer inspection, however, 
differences will be noticed. The measles spot is much less raised than the 
small-pox papule, and is not hard and resisting to the finger. Moreover, 
in measles the cough, coryza, and lachrymation are significant symptoms, 
and are quite absent in the early period of variola. The temperature, too, 
is less elevated in measles during the stage of invasion than in small-pox. 
In measles it is usually between 102.5° and 104°, while in variola it is often 
between 105° and 106 D . After a day or two the change of the papule into 
a vesicle removes any doubts that may have been entertained as to the 
nature of the illness. 

The roseolous rash which sometimes precedes the papular eruption 
may be mistaken for scarlatina. It is distinguished from it by noting its 
less complete diffusion over the surface, its brighter tint, and more mottled 
character. Moreover, according to M. See, in cases of small-pox, when the 
roseolous eruption is present, the variolous papule has already begun to 
appear, and may be discovered by careful examination. 



62 DISEASE IN CHILDREN. 

The remission of the fever, which often takes place when the papular 
eruption is completed, cannot be relied upon for diagnosis, as it is very 
uncertain. In the boy whose case was referred to at the beginning of 
this chapter there was no remission of the fever at the early period of the 
eruptive stage. On the contrary, the temperature rose still higher, and 
when the patient was sent away to the smali-pox hospital on the third day 
of the rash, the spots being then vesicular, his temperature (at 8 a.m.) was 
103.4°. 

Varicella may be readily mistaken for modified small-pox. The differ- 
ences between the two diseases are described elsewhere. 

Prognosis. — The mortality from small-pox in childhood is very high up 
to the age of ten years. Infants usually succumb to the disease even in 
the discrete form. The previous health of the child is an important item 
in estimating his chances of recovery, for weakly children have small pros- 
pect of passing safely through so formidable a trial. Little information 
can be gained from the severity of the initial stage, for violent convulsions 
may usher in a benign form of the disease. Remission of the fever and 
constitutional symptoms at the beginning of the eruptive stage, scantiness 
of the rash, normal development of the spots, and absence of subcutaneous 
hemorrhages, are favourable symptoms ; but even in these cases a serious 
complication may arise during the third stage and carry off the patient. 

Of special symptoms, profuseness of salivation is not an unfavourable 
sign, although it occasions much discomfort. Mr. Marson even regards it 
as of auspicious omen, especially if combined with much swelling of the face 
and marked tenderness of the skin. Bleeding from a mucous surface, if 
limited to one tract of that membrane, is not, according to Dr. Collie, to be 
viewed with apprehension ; but if more than one tract is a source of 
hemorrhage, the prognosis is very unfavourable. Hematuria is not neces- 
sarily dangerous ; but hemorrhage into the skin, if anything more than a 
few scattered petechise can be seen, is of very serious import. 

Destructive ulceration of the eyes may be expected in cases of the con- 
fluent form of the disease when the secondary fever is high and the skin 
is very hot and dry. If, in such a case, the eyes do not suffer, some other 
serious complication is certain to occur, according to Mr. Marson. The 
same authority asserts that if an ulcer be found at the same time on each 
side of the cornea, that eye will be entirely destroyed. 

Treatment. — In varioloid and the milder cases of discrete small-pox the 
child merely requires to be kept in bed in a large well-ventilated room, 
and to be fed with such articles of diet as are suitable to his age and de- 
gree of pyrexia. While the fever is high, he should take nothing but milk 
and broth ; but when the pyrexia subsides, he may take fish or once cooked 
meat, light puddings, etc. His whole body should be sponged daily with 
tepid water, and if there is much heat of skin, this process may be repeated 
several times in the twenty-four hours. He maybe allowed to drink freely 
of pure cold water, and his bed and body linen should be changed every 
day. No medicine will be required unless constipation be present, when 
a moderate dose of castor-oil is indicated. As in scarlatina, the room 
should be cleared of all carpets, rugs, curtains, and other woollen fabrics 
not absolutely indispensable. Open windows, whatever be the season of 
the year, are insisted on by Dr. Collie. 

The severer forms of the disease, and especially the confluent variety, 
require very careful treatment. The diet should be liberal, given in such 
form as the child can digest, and in quantity suitable to his power of as- 
similation. Milk, strong beef-tea, essence of meat, yolks of eggs, light 



SMALL-POX — TREATMENT. 63 

puddings, and jelly can be given frequently and in small quantities at a 
time. Stimulants, such as brandy and the brandy-and-egg mixture, will 
also be needed whenever signs of failure of strength are observed. It is 
best, however, to withhold stimulants during the earlier period of the ill- 
ness, unless they are imperatively required, for they will certainly be 
wanted at the end of the second or beginning of the third week, when com- 
plications generally appear. 

If the patient be restless at night and wakeful, a little chlorodine may 
be given cautiously ; but we must be careful in giving narcotics, partly on 
account of the easily depressed condition of the patient, partly because 
the air-passages become readily choked by the abundant mucous and sali- 
vary secretion. 

The treatment of the skin eruption is an important matter ; for in 
small-pox, unlike the other eruptive fevers, the dermatitis which accompa- 
nies the maturation of the pustules may produce severe local injury as well 
as marked constitutional disturbance. Very many different methods have 
been recommended and adopted for checking the ulcerative process and 
preventing pitting of the skin ; but none of these can be said to be success- 
ful. The application of salves of various kinds appear to be useful, but 
rather through the oil or fat they contain than through the chemical ingre- 
dient which was supposed to give them their value. Dr. Collie pronounces 
against distressing the patient by efforts in this direction, which are cer- 
tain to prove ineffectual, and merely recommends the use of olive-oil to 
the skin. A thirtieth part of carbolic acid increases the value of this appli- 
cation. German writers speak highly of cold compresses to the face and 
hands, and to any other part where the eruption is copious. They state 
that the application diminishes pain, heat, and redness, and contributes 
greatly to the comfort of the patient. 

The sore throat is best treated by barley-water and other mucilaginous 
drinks. A draught containing perchloride of iron and glycerine, taken 
three times a day, is often of service. 

At the end of the second week we must be on the watch for complica- 
tions. Laryngitis is often the first to appear, and indeed this intercurrent 
disorder may begin as early as the tenth day. When this complication oc- 
curs, the room must be kept warm (a temperature of 70° is sufficient) ; the 
cot must be surrounded with an atmosphere of steam from some one of the 
many apparatus constructed for this purpose ; and the throat should be 
enveloped in hot linseed-meal poultices. Stimulants must be given as 
seem desirable. If signs of suffocation are noticed, tracheotomy should be 
performed at once. In cases of oedema of the glottis, where life is in the 
greatest danger, and immediate measures have to be taken to avert a fatal 
issue, much benefit may be derived from rapid vesication. This is best 
done by means of boiling water. Dr. Owen Bees directs that the corner 
of a towel should be soaked in water as this boils on the fire, so as to ac- 
quire the full temperature, and that it should be then applied rapidly to 
the region of the throat. Before doing so, the surrounding parts which it 
is not wished to blister must be covered with thick cloths. 

Diarrhoea, if it be troublesome, must be treated with a small dose of 
castor-oil, followed up, if necessary, by a draught containing dilute sul- 
phuric acid and a drop or two of tincture of opium. An enema of starch 
with five or ten drops of laudanum is also useful. If the diarrhoea resist 
this treatment and become exhausting, nitrate of silver or gallic acid and 
opium must be resorted to. 

The various forms of chest affection must be treated upon general prin- 



64 DISEASE IN CHILDREN. 

ciples. They are excessively dangerous. As the patient is usually by this 
time in a state of great exhaustion, stimulants must be given liberally ; and 
strong beef-essence and other forms of food containing much nourishment 
in small bulk must be administered in small quantities at a time. 

If an ulcer appear upon the cornea, it should be touched with a solution 
of nitrate of silver (gr. xx. to the ounce), and afterwards some olive-oil should 
be dropped into the eye. A blister to the temple is also of service. The 
conjunctivitis may be treated in mild cases by a solution of sulphate of zinc 
(gr. iij. to the ounce), dropped into the eye three or four times a day ; or a 
solution of the nitrate of silver (gr. j. to the ounce) may be used. If the case 
is severe, with much muco-purulent discharge, Mr. Makuna recommends 
the stronger solution of the nitrate to be dropped into the eye once a day. 
The lids may be prevented from adhering by bathing frequently with warm 
water, and then placing a drop of castor-oil between them. 

Abscesses must be opened early. Any sign of suppuration is a signal 
for stimulants, and for quinine with or without per chloride of iron. 

If haemorrhage occur, the patient must be kept perfectly quiet, and stim- 
ulants must be given as required. 

In all cases where the skin eruption is profuse, cleanliness is of the ut- 
most importance. Dr. Collie especially directs the removal of all crusts 
about the nostrils and lips as they form, for they poison the air as it enters 
the body of the patient. He also insists upon the early removal of all 
scabs under which pus is forming, and recommends that the patient be 
bathed daily in a bath medicated with carbolic acid. He also points out 
the necessity of frequent changing of the body linen. If, as often happens, 
the child's head is slow in recovering, the scabs must be removed by poul- 
ticing, and zinc ointment must be applied, or the following : 

3« Liq. plumbi subacetatis 3 j. 

Zinci oxydi 3 j. 



Vaseline \ 



M. 



!J- 



Cod-liver oil and iron are also indicated. 

In the malignant form of the disease no treatment is successful, and the 
patient invariably dies. 



CHAPTER VII. 

MUMPS. 

Mumps, or Parotiditis, is one of the milder infectious disorders of child- 
hood. It is rare in infancy, and cannot be said to be common before the 
fourth or fifth year. Again, after puberty the liability to the disease di- 
minishes. It seldom occurs a second time in the same subject. Mumps 
is usually epidemic, and is especially common in the spring of the year. 
Its infectiousness is extreme, so that if the complaint break out in a 
school, or other institution where young people are congregated together, 
few are likely to escape. The virus is supposed to be conveyed in the 
breath. The duration of the illness is from a week to ten, twelve, or four- 
teen days. There is, besides, a period of incubation which has been 
variously estimated at from one to three weeks. 

Morbid Anatomy. — The disorder consists in an inflammation of the ducts 
of the parotid and other salivary glands, with infiltration of the cellular 
tissue of the glands. Exudation also invades the subcutaneous tissue for 
some distance around, so that very widespread swelling may be the con- 
sequence. The diseased action does not go on to suppuration, but ter- 
minates in resolution in the course of a few days. 

Symptoms. — After a period of incubation which, according to Dr. 
Dukes, varies from sixteen to twenty-five days, the earliest signs of the dis- 
order are noticed. The first symptom is fever, which usually precedes by 
some hours any sign of local discomfort. The temperature is generally 
high, rising sometimes to 103°, and, as is often the case with children, the 
pyrexia is apt to be accompanied by headache and vomiting. Swelling of 
the parotid gland may occur at the same time as the fever, or may even 
precede it. In any case attention is soon attracted to the face. Aching 
and tenderness are complained of, situated immediately below the ear, 
and behind the ascending ramus of the jawbone ; and on inspection the 
normal depression between the face and the neck is found to have disap- 
peared. The swelling strikes forward into the face, and backward and 
downward into the neck, so that when fully developed it covers the whole of 
the parotid region. If, as often happens, the inflammation extends to the 
submaxillary glands, and attacks both sides, the familiar face is curiously 
disfigured, and is scarcely recognizable by the friends. It is enormously 
widened at the level of the nose and lip, and the chin may almost dis- 
appear in the swelling of the neck. The swelling is very tense and elastic, 
and is extremely sensitive to pressure. The skin over it is either pale or 
is suffused with a rosy-red blush. The full development of the swelling 
occupies from three to six days ; then, after remaining unaltered for one 
or two days longer, it begins to subside, and by the tenth or twelfth day 
from the beginning of the disorder all fulness has disappeared. During 
the whole of this time the aching continues, and is greatly intensified by 
movement of the jaw ; so that mastication becomes impossible, speech is 
5 



66 DISEASE IN CHILDREN. 

hampered, and even swallowing is difficult and painful. One consequence 
of this is that saliva tends to accumulate in the mouth, and is a cause of 
much discomfort. Fortunately, however, its secretion is seldom greater 
than natural. 

While the disease is in progress the fever remains high. When the 
swelling has reached its full development, the temperature falls, suddenly 
or gradually, and during the process of resolution the heat of the body is 
natural. The disease seldom attacks the two sides of the face quite si- 
multaneously. One side generally precedes the other by some hours or 
days. In rare cases the inflammation remains limited to the gland first 
attacked. 

Although the parotid glands are primarily and principally affected in 
the large majority of cases, this is not the invariable rule. Sometimes the 
inflammation is localized in the submaxillary glands, and the parotids suffer 
little if at all. Dr. Penzoldt, of Erlangen, in an epidemic of undoubted 
mumps occurring in that town, noted some cases in which the swelling of 
the parotids was so slight as to be scarcely observable, while the sub- 
maxillary glands were considerably enlarged and very painful. In one 
case there was in addition swelling and redness of the tonsils. 

One of the most curious features of this disorder consist in the metas- 
tases which occasionally occur. As the inflammation subsides, or even a 
day or two after the swelling has disappeared, a similar condition develops 
itself in a distant part — the testicle, in the case of a boy ; the breast, if the 
patient be a girl. These complications are accompanied by fever and gen- 
eral poorliness, but subside in the course of a few days. In rare cases 
orchitis has been known to precede the affection of the parotid gland. 
Thus, a young gentleman described to me how he had had an attack of 
orchitis, accompanied by severe pain but a normal temperature. At this 
time there was absolutely no s} 7 mptom connected with the face. Sixteen 
hours afterwards, however, slight swelling and tenderness of the parotid 
gland began to be noticed, and the temperature was found to be 100.6°. 
As the mumps subsided, the second testicle became inflamed. In this 
attack the temperature rose to 105°, and for some days was as high 
as 104°, with delirium and distressing vomiting. Sometimes the appear- 
ance of swelling in the organ secondarily attacked is preceded by severe 
constitutional symptoms. There may be high fever and delirium ; or 
great prostration w T ith coldness of the extremities ; or violent vomiting and 
purging. In any case, great alarm is excited by the condition of the suf- 
ferer ; but all apprehensions are removed by the appearance of the local 
lesion. These complications are less common in children than in adults 
who suffer from mumps, but it is well to remember that it is possible they 
may occur. 

There is another and occasional after-consequence of mumps which it 
is important to be acquainted with. This is deafness, coming on some 
time after the parotiditis has subsided. The hearing may be affected in 
one of two ways. An extension of the inflammation may take place to the 
Eustachian tube and middle ear. These cases are very amenable to treat- 
ment and usually recover. There is, however, another class of cases of a 
much more serious character, to which attention has been directed by Mr. 
Dalby. In these the deafness comes on quite suddenly. The child goes 
to bed with his hearing perfect ; in the morning he is found to be deaf. 
Little can be done for this form of deafness. It is probably dependent 
upon some altered condition of the auditory nerve, for no appreciable lesion 
can be detected in the auditory apparatus. Whether the loss of hearing 



MUMPS — DIAGNOSIS— TBEATMENT. 67 

be complete or merely partial, little hope of material improvement can 
be entertained. 

In some rare cases an attack of mumps lias been known to be accom- 
panied by facial paralysis from extension of the inflammation to the Portio 
Dura. 

Diagnosis. — Mumps can only be confounded with inflammation of the 
parotid gland of a non-specific character, such as may occur in the course 
of some fevers— symptomatic parotiditis, as it has been called, or parotid 
bubo. In this case both sides of the face may be attacked, but the fact of 
the lesion being a secondary, and not a primary disease, and of the rapid 
suppuration which takes place when the inflammation is symptomatic, 
should clear up any uncertainty which might be felt as to the nature of 
the case. 

Mumps is probably infectious from the very beginning of the disorder, 
and remains so for some time after the swelling has subsided. Dr. Squire 
is of opinion that for at least two weeks after the disease has cleared away, 
the child should not be allowed to return to his healthy companions. 

Treatment. — As the disease cannot be arrested, but must run its course, 
little active treatment is required. It is best to put the child to bed, and 
to keep him there as long as the temperature is elevated. Hot poultices 
should be applied to the parotid region and be frequently changed. If the 
pain be not relieved by this means, an ointment composed of equal parts 
of extract of belladonna and glycerine may be smeared gently upon the 
skin over the inflamed glands, and the poultice be applied as before. The 
jaws must be kept at rest, and no solid food can be allowed. Instead, the 
child should have strong beef-tea or gravy soup, meat jelly, milk, yolks of 
eggs, etc. ; but if there be high fever, with foul tongue and derangement 
of the digestive organs, as is most usually the case, the stomach must not 
be overloaded even with liquid food, and care should be taken to supply 
nourishment in small quantities at a time. If the fever be high and cause 
restlessness, the surface of the body can be sponged with tepid water. 
The bowels must be attended to and constipation relieved by some gentle 
aperient, such as compound liquorice powder or the liquid extract of 
rhamnus frangula. 

In cases of metastasis to the mamma or testicle, perfect rest must be 
enforced ; and the local treatment recommended for the face should be 
had recourse to. The alarming symptoms which sometimes precede the 
appearance of the secondary lesion usually pass away in the course of a 
few hours. If there be great prostration, stimulants must be given, and 
warmth be applied to the extremities. 



CHAPTEE YIII. 

CEREBROSPINAL FEVER. 

(Epidemic cerebro-spinal meningitis.) 

Ceeebeo-spinal fever is a specific inflammation of the membranes cover- 
ing the brain and cord. The malady is no mere local disorder, but a 
blood disease, of which the inflammatory affection of the meninges is the 
anatomical expression. It usually prevails in epidemics, and outbreaks 
of the disease have been noted in various countries widely differing in 
climatic and other conditions. 

Gaumtion. — The epidemics of cerebro-spinal fever generally occur dur- 
ing the winter months ; but isolated cases are often noticed for some time 
before the disease becomes more generally diffused. Thus, before the epi- 
demic which prevailed in Ireland in 1867, sporadic cases had been observed 
in the country for some years. The disease aj)pears to be mildly infectious. 
It fastens upon old and young, rich and poor, but males appear to be more 
liable to suffer from it than females. In 1846 some cases occurred in the 
Dublin and Bray Workhouses, and shortly afterwards in the Belfast Work- 
house. In these cases the sole victims were boys under the age of twelve. 
The girls and adults escaped. In all epidemics children are largely affected, 
for unlike typhus, of which cerebro-spinal fever was at one time supposed 
to be merely a variety, the disease readily attacks young subjects, and is 
most fatal in early life. Although not generated, like typhus, by insanitary 
conditions, the onset of the fever seems to be favoured by them ; and foul 
air, bad food (especially ergotized grain, according to Dr. Richardson), 
exposure to cold and damp, and physical fatigue, no doubt tend to encourage 
the spread of this fatal malady. 

Morbid Anatomy. — The vessels of the pia mater, both of the brain and 
cord, are congested, and lymph is exuded into the subarachnoid tissue. 
Sometimes it is also seen in the ventricles. It usually consists of opaque 
purulent matter of a greenish-yellow color. The amount varies. It may 
occur only in patches, or may be more general. The lymph is especially 
abundant at, or is confined to, the base of the brain — usually the posterior 
portion, the surface of the medulla oblongata, and the upper part of the 
spinal cord. There is often congestion of the substance of the brain, and 
there may be serous effusion or actual extravasation of blood. The choroid 
plexus is much congested, and the cervical part of the cord may be cov- 
ered with a thick layer of bright-red vessels. In the worst cases of the 
disease the blood is very dark in colour and unusually liquid. 

The exudation appears to be thrown out with great rapidity, for it may 
be found in cases where death occurred within a few hours of the child 
being attacked. Ebert and others have found micrococci in the purulent 
effusion of the meninges, and according to some observers the disease is 
essentially due to micro-organisms. 



CEREBROSPINAL FEVER — MORBID ANATOMY — SYMPTOMS. 69 

Of the other organs : the spleen is generally unaltered, although 
sometimes it. as well as the other viscera, may be congested. There may 
be signs of pleurisy, and scattered patches of hepatization may be seen in 
the lungs. It is said that the agminated and solitary glands of the intestine 
have been found in some cases to be swollen. 

Symptoms. — The disease generally begins suddenly during sleep, hav- 
ing been preceded by few or no premonitory symptoms. In certain cases 
— usually the milder ones — the child may complain, if old enough to do so, 
of wandering pains, and may seem poorly for a day or two before the out- 
break ; but there is seldom anything to fix the attention before the first 
violent symptoms of the disease make their appearance. In rare cases 
there may be headache, vomiting, and general tenderness for some days 
previous to the actual beginning of the illness. 

As a rule, the first noticeable f eature is a rigour or a fit of convulsions ; 
and the younger the child, the more likely is the attack to begin with a 
convulsive seizure. Sometimes severe headache and vomiting may usher 
in the disease. If the patient, as is often the case, seems heavy and 
stupid after the fit, he still shows by his restlessness, his moans and cries, 
and by frequently carrying the hand to the head, that he is suffering se- 
vere pain. The pupils are contracted ; the pulse is quick, seldom lowered 
in frequency ; the temperature (which should always be taken in the rec- 
tum) is 101-2° ; and the breathing is hurried. An early symptom is re- 
traction of the head upon the shoulders. It has been suggested that this 
position is at first partly voluntary, to relieve the pain (which we know, from 
the case of the adult, to be of a very severe character) shooting down the 
back ; but it soon becomes involuntary from spasmodic contraction of the 
muscles of the nucha. It may occur within a few hours of the onset of 
the illness, and is rarely delayed beyond twenty-four hours. The tetanic 
spasm of the muscles of the neck may extend to the whole back, the jaws, 
or even the limbs, and may be varied by clonic convulsive movements. 
In a short time the cries and manifestations of pain cease as the senses be- 
come duller and the stupor increases. If consciousness is lost early and 
does not return, the symptom is a very grave one. 

About the second or beginning of the third day a herpetic eruption 
appears upon the face, and purpuric spots may come out upon the body 
and limbs. This eruption, which is not invariably present, has given to 
the disease one of its names — " spotted fever. " 

When the disease is at its height, the child lies on his side in the cot 
with his head retracted, his limbs flexed, and his spine often rigidly 
curved. He is completely unconscious, but still remains uneasy and rest- 
less, often moving one or both lower limbs monotonously. The pupils 
are now generally dilated, usually sluggish, and perhaps unequal. The 
belly is flattened ; the bowels are constipated ; the pulse and respirations 
are quickened. At intervals spasms are noticed ; the head is drawn more 
backward, and the curve of the spine is increased. When the stupor is 
complete the bladder is evacuated involuntarily, or there is retention of 
urine. 

In fatal cases the coma continues, the breathing is accompanied by 
rattling within the chest, and the child sinks and dies. If the case is to 
end favourably, the stupor grows less profound and the restlessness dimin- 
ishes. The rigidity is late in relaxing, and usually the mind becomes 
clear while the head is still retracted upon the shoulders. 

The special symptoms above referred to vary considerably in severity 
in particular cases : — 



70 DISEASE IN CHILD PwEN. 

The fever is very variable and has no regular course. The internal 
heat, as tested by a thermometer introduced into the rectum, is generally 
higher than the surface of the body ; but even in the rectum the mercury 
may only mark a degree over the normal temperature. At other times it 
rises to 104° or 105°. If early collapse come on, the temperature may 
sink to below the normal level. 

The skin eruption is a valuable sign. In some epidemics it is a rare 
symptom ; in others almost all the cases exhibit a number of purpuric 
spots. In every recorded serious outbreak both the maculated and the 
non-maculated forms of the disease have been observed, although one may 
have been more common than the other. The rash consists of dark 
purple spots or blotches due to effusion of dissolved hsematin into the true 
skin and areola tissue beneath it. They generally occupy the legs, hands, 
face, back, and neck. They are sometimes slightly elevated, and vary in 
size from a pin's head to a walnut. According to Dr. J. A. Marston's ob- 
servations in the epidemic which occurred in Ireland in the year 1867, 
there is no necessary relation between the occurrence, the number, and the 
extent of the spots upon the skin and the amount of the intra-cranial and 
intra-spinal mischief. Dr. Mapother, referring to the same epidemic, 
states that the spots cannot be produced artificially by pressure on the 
skin as in true purpura. Besides the petechise, there may be herpes, 
urticaria, and patches of erythema or roseola. The skin may have a 
dusky tint and is often moist. Cerebral flush is not a marked symptom. 

The mental condition also varies in different cases. When the disease 
is violent and death occurs early, the child may be unconscious from the 
first. In other cases stupor comes on by the second or third day. In the 
mildest cases the mind may be little affected, or there may be slight de • 
lirium with curious hallucinations. Thus, Dr. Lewis Smith refers to a 
case in which the child answered questions with perfect clearness, but 
constantly mistook his mother for another person. Usually, in all cases 
before death the coma is profound. 

The pains referred to the head and spine are always a distressing and 
prominent symptom. They are often so severe that the child, until 
he becomes comatose, is constantly moaning and screaming. The pain is 
increased by movements of the back, and especially by attempts to press 
the head forward. The general tenderness of the skin adds greatly to the 
child's discomfort ; and sometimes a touch on the body, as in moving him 
to alter his position, causes the greatest distress. 

In some cases paralysis is noticed. It is, however, a comparatively rare 
S3 T mptom, and is usually partial, being limited to one or more limbs. It 
may affect the cerebral nerves, especially the third, the sixth, and the 
facial. The lesion of the nerve-trunks is due to purulent infiltration of 
the neurilemma, or to contraction of the hyperplastic connective tissue of 
the nerve-sheath. In cases of recovery the paralysis may last through life, 
but sometimes it passes off as the patient improves. 

Convulsions, general or partial, are comparatively common in the case 
of children, certainly much more common in them than in the adult. They 
are especially frequent in the more severe forms of the disease. The clonic 
spasms sometimes alternate with tonic contractions ; and may be general 
or limited to one-half of the body. Nystagmus may be noticed. 

Vomiting is seldom absent at the beginning of an attack. It is often 
severe, and like all forms of nervous vomiting is independent of taking 
food. The thirst is great. Constipation is the rule ; although in some epi- 
demics the disease has been noticed to be ushered in by purging as well as 



CEREBROSPINAL FEVER — SYMPTOMS. 71 

vomiting. The tongue may be clean or furred ; towards the end of the 
disease it becomes dry. Abdominal pain, if present, is like the hyperes- 
thesia of nervous origin. The belly is seldom retracted, and never to the 
degree observed in cases of tubercular meningitis. Occasionally it is full 
or even tympanitic. The spleen is sometimes enlarged. 

The pupils are at first contracted, but dilate as the stupor deepens. 
They are often sluggish, and may be unequal in size. A squint is some- 
times noticed. Blindness may occur from keratitis owing to imperfect 
closure of the eyelids, or from neuro-retinitis due to the spread of the 
purulent inflammation along the optic nerve ; and in some rare cases the 
eyeball has been known to be completely destroyed by suppuration. The 
hearing may be also affected. A temporary deafness with noises in the 
head may occur during the first days of the disease and be afterwards re- 
covered from. If it occur later, it is probably due in most cases to purulent 
inflammation within the labyrinth. This form of deafness is usually bi- 
lateral, complete, and permanent ; and if the patient be a young child, may 
lead to deaf-mutism. 

The pulse is seldom otherwise than quickened ; but it rarely attains at 
first a high degree of frequency, and is subject to rapid alternations. It is 
not often intermittent, but is usually very feeble. The breathing is also 
quickened, and is often irregular and interrupted with sighs. The normal 
relation between the pulse and the respiration is preserved. 

The urine is often natural in quantity, color, and reaction. It has been 
known to contain albumen and even blood. 

There are many differences in the various cases of cerebro-spinal fever 
met with in the course of the same epidemic. In some the symptoms from 
the first are indicative of profound blood-poisoning. Consciousness is af- 
fected from the beginning ; there is extreme prostration, a feeble flutter- 
ing pulse, and labored breathing. Then spots appear early and are ex- 
tensively distributed. The stupor deepens into coma, and death takes 
place with startling rapidity. In these cases the more special symptoms 
arising from the local inflammation are overshadowed by those dependent 
upon the general condition, and the patient dies from blood-poisoning. In 
another class of cases the symptoms of cerebro-spinal inflammation pre- 
dominate, and the more marked phenomena are the convulsions, the draw- 
ing backward of the head, the hyperesthesia, and the tetanic contraction of 
muscles. In this form if the disease end unfavourably, death is owing mainly 
to the local lesion. As a rule, the affection is most severe when the epidemic 
is still young. As the cases get more numerous they become milder ; and 
at the end of the epidemic it is common for recoveries to take place. 

In some instances curious intermissions occur in the disease. These 
may be found quite at the onset, evident premonitory symptoms appearing, 
passing off, and returning, perhaps several times, before the actual out- 
break occurs. In other cases during the course of the disease more or less 
complete remission of the symptoms lasting for several hours or a day may 
take place. According to Dr. Trey, this is very common at the end of the 
second or third day. Again, during convalescence the same variations 
may be seen, the headache and retraction of head being at times distress- 
ing, at other times scarcely noticeable. 

According to Dr. Oscar Medin, of Stockholm, infants under twelve 
months old are especially liable to the disease. At this early age the ill- 
ness generally ends fatally ; but sometimes mild cases are observed lasting 
from a day to a week. This physician, who at the Orphan As}dum of 
Stockholm had many opportunities of observing the malady, states that the 



72 DISEASE IN CHILDREN. 

mild cases began with fever, somnolence, and twitchings during sleep. In 
most instances there were other symptoms, especially during sleep, such as 
restlessness, great heat of head, changes in the colour of the face and in the 
sensibility of the body. In a few of the milder cases slight convulsive 
spasms were noticed, with rigidity of the limbs and neck, strabismus, and di- 
latation of the pupils ; but in such cases these symptoms soon disappeared. 
In all the epidemics which came under Dr. Medin's observation such mild 
cases were the exception, and a large proportion of the infants died. In 
the severer forms the symptoms did not differ from those observed in older 
children. 

Dr. Medin, like other observers who have had opportunities of study- 
ing this form of illness, speaks of a pneumonia of a low type, occurring 
without nervous symptoms, as being frequently present in epidemics of 
cerebro-spinal fever ; and holds with them that in such cases, the infective 
material attacks the lungs in place of the cerebral membranes. Still, 
meningitis may be present in such cases, although it gives rise to no symp- 
toms ; for in some instances where during life the symptoms were exclu- 
sively pulmonary, inflammation of the cerebral and spinal meninges was 
discovered on post-mortem examination of the body. Besides pneumonia, 
peri- and endo-carclitis, pleurisy, parotitis, and purulent effusion into the 
joints may be complications of the disease. 

The duration of the attacks is very variable. Death may take place in 
five or six hours in the most malignant forms of the distemper. In other 
cases the illness may be prolonged for ,one, two, three, or four weeks, or 
even longer. Convalescence is always slow, and is often intermittent. A 
profound debility, lasting for a long time after the fever is at an end, is one 
of the characteristics of the malady. 

Diagnosis. — Every case of rigid retraction of the head in a child is not 
one of cerebro-spinal fever. The symptom is the consequence of a basic 
meningitis spreading to the cervical portion of the spinal cord ; and it may 
therefore be present in any case where the membranes of the brain are the 
seat of inflammation. It is not uncommon in the course of a tubercular 
meningitis. 

Cerebro-spinal fever not only gives rise to severe local symptoms, but 
is also accompanied by more general phenomena indicating a profound con- 
stitutional affection. Its epidemic form, its violent and abrupt onset, the 
extreme debility which is invariably present, and the petechial rash, remove 
the disease from the list of purely local disorders, and amply justify its be- 
ing ranked amongst the specific fevers. The disease was at one time held to 
be merely a form of typhus fever complicated with meningitis ; but the 
difference between the two diseases are neither insignificant nor few. Cere- 
bro-spinal fever prevails equally amongst the rich and the poor ; it particu- 
larly affects children, and is very fatal to them ; it runs a rapid course, 
often causing death in a few hours ; its temperature as a rule is little ele- 
vated ; the rapidity of the pulse is moderate, and when the fever is high, 
is not increased in proportion to the degree of pyrexia (indeed, according 
to some observers, it does not become rapid until the temperature falls) ; 
lastly, retraction of the head is one of the most common symptoms. 

Typhus loves "fever haunts," and seldom attacks the well-to-do; it 
rarely affects children, and if it do, runs in them as a rule an especially 
favourable course ; its duration is longer, and even in the adult it rarely ap- 
pears in the overwhelming and malignant form so often seen in cases of 
cerebro-spinal fever ; lastly, meningitis with retraction of the head is a rare 
complication. 



CEREBROSPINAL FEVER — DIAGNOSIS— PROGNOSIS. 73 

The diagnosis of cerebro-spinal fever is much easier in the midst of an 
epidemic of the disease. The abrupt and violent onset, the severe pain in 
the head and spine, the vomiting, the retraction of the head, the general stu- 
por, and the petechial and other eruptions — this combination of profound 
constitutional symptoms with nervous excitement followed by depression, 
is sufficiently characteristic, especially if at the same time, as often hap- 
pens, the temperature is only moderately raised and varies irregularly. In 
cases of simple cerebro-spinal meningitis the retraction of the head is not 
so extreme, and the stiffness and pain in the spine, the hyperesthesia, and 
the pains in the joints are seldom present. As a rule, too, the non-specific 
disease is preceded by prodromata and runs a less rapid course. Still, this 
is not always, the case, for in exceptional instances simple meningitis may 
prove fatal to a young child in the course of twenty-four hours. The fever 
in the latter is, however, always high, and the convulsions are in most 
cases repeated and general. 

It would be difficult to confound tubercular meningitis accompanied by 
retraction of the head with cerebro-spinal fever. The hereditary tubercu- 
lar tendency, the long prodromal period, the gradual onset of the illness, 
the more protracted and characteristic course, and the slow intermittent 
pulse, would serve to distinguish the tubercular disease. 

In infants under twelve months old the disease is very difficult to de- 
tect. It may, however, be distinguished by close attention to the course 
and symptoms of the illness ; especially if the case occur in the midst of an 
outbreak of the malady. 

Prognosis. — In all cases of cerebro-spinal fever the prognosis is very 
serious. The disease is especially fatal to children, and the younger the 
patient the less hope can we entertain of a favourable termination to his 
illness. 

In babies an arched and tense fontanelle, which shows the presence of 
profuse exudation and oedema, is a very grave symptom. In all cases re- 
peated convulsions and signs of severe nervous excitation, such as violent 
and incessant vomiting, intense cephalalgia and pain in the back, strong 
tetanic spasms ; also early appearance of depression, continuous coma or 
return of the stupor after a period of apparent improvement, and irregular 
breathing, are all signs calculated to excite the gravest apprehensions. 

Treatment. — The disease unfortunately is little amenable to treatment. 
In all cases ice-bags should be applied to the head and spine as long as the 
period of excitement continues. When symptoms of depression are no- 
ticed, the ice should be removed, or supplemented by the application of 
hot bottles to the feet, and the administration of stimulants by the mouth. 
Sometimes hot applications relieve the severe headache better than cold. 
The ether spray has been used to the occiput and back of the neck, and is 
said to be of service. Large doses of chloral sufficient to produce signs 
of narcotism have been recommended. All writers, however, speak highly 
of the subcutaneous injection of morphia. For a child of three years of 
age one-twentieth of a grain may be used, and repeated every one or two 
hours until some sensible effect is produced ; or four or five grains of 
chloral may be given by the mouth. 

During protracted convalescence the iodide of potassium must be given 
to further absorption of the exudations ; and iron and tonics, with removal 
to a dry bracing ah-, are of value to hasten the child's recovery. 



CHAPTEK IX. 

ENTERIC FEVER. 

Enteric or tj^hoid fever is common in cliildren. A large proportion 
of the cases formerly described as "Infantile Kemittent Fever" were no 
doubt cases of this disease. Fortunately in young subjects typhoid fever 
usually runs a mild course. It would be, no doubt, too much to say that, 
properly treated and nursed, no child should die of typhoid ; but certainly 
when placed from the beginning under favourable conditions for recovery, 
death in the child from such a cause is very rare. 

Infants and children during the first four or five years of life seem less 
susceptible to the typhoid poison than at a later age. Perhaps, however, 
it is difficult to recognize the disease in such young subjects ; and it is not 
impossible that many cases of febrile diarrhoea in the young child may be 
cases of typhoid fever which have escaped recognition. Boys are more 
commonly affected than girls ; and the fever seems to attack by preference 
previously healthy children. At any rate the patients who are brought 
suffering from the disease to the Children's Hospitals are generally well- 
nourished, strong-looking little persons, with exceptionally good histories. 

Causation. — It is now well known that enteric fever arises as the con- 
sequence of absorption into the system of a specific poison which is gen- 
erated by the decomposing discharges of typhoid patients. It is therefore 
largely distributed by the emanations from cesspools and faulty drains. 
Warm weather, which encourages putrefaction, increases the prevalence of 
the fever. Dr. Murchison has shown, from the records of the London 
Fever Hospital, that cases of enteric fever become more numerous after the 
warmth of summer, and diminish in number after the cold of the winter 
months. Thus, in August, September, October, and November, the fever 
prevails largely ; while in February, March, April, and May, it is much 
less frequently seen. Whether the poison can be generated de novo is a 
question which has been often debated and on which opposite opinions 
are held. It seems certain that the decomposition of ordinary fecal 
matter under ordinary conditions of atmosphere cannot produce it ; but it 
is probable that the specific poison may be generated from non-specific 
ordure under extraordinary conditions. At least, it is difficult under 
any other hypothesis to explain outbreaks of the fever in country villages 
where the strictest search fails to discover any means by which the disease 
can have been imported from without, and in which the same insanitary 
state has existed unchanged for years. There is no doubt that the dis- 
charges fi-om the patient are highly contagious. The disease cannot, how- 
ever, be communicated by the breath or by emanations from the skin. It 
is held by some that the discharges themselves are at first comparatively 
innocuous, and only become hurtful after putrefaction has begun. 

The poison enters the system by the mucous membrane of the lungs 
or of the alimentary canal. In most cases ; no doubt, contaminated water 



ENTERIC FEVER — CAUSATION — MORBID ANATOMY. 75 

is the means by which it is conveyed. Several epidemics of typhoid fever 
in London, of late years, have been traced to milk to which water contain- 
ing typhoid matter had been added. It is also probable that untrapped or 
faulty drains, allowing the effluvia of cesspools charged with the specific 
poison to penetrate into a house, may be another means of imparting the 
disease. 

One attack of typhoid fever does not necessarily protect against anoth- 
er ; and relapses are very common. 

Morbid Anatomy. — The characteristic lesion in typhoid fever consists in 
a swelling of the solitary glands of the small intestine, of the agminated 
glands constituting Peyer's patches, and of the mesenteric glands in con- 
nection with them. The swelling is a pure proliferation of the cellular 
elements, which are seen by the microscope to be much increased in num- 
ber. Some corpuscles become enlarged and develop smaller cells within 
their walls. The hypertrophic change in the glands begins early, prob- 
ably at the beginning of the disease, and proceeds rapidly. It involves a 
certain number of Peyer's patches. These are fully developed by the 
ninth or tenth day, and form thick oval plates with abrupt edges and an 
uneven, mammilated surface. Their consistence is softer than natural, and 
more friable. The solitary glands may be unaffected ; but they also often 
swell and form small projections from the surface of the mucous mem- 
brane. After reaching their full size the glands, in mild cases, begin 
slowly to shrink. The newly proliferated cells undergo a fatty degeneration 
and are absorbed. The mesenteric glands also diminish in size by the 
same process of fatty degeneration, and gradually resume their former 
dimensions. 

In more severe cases the diseased glands, instead of undergoing 
healthy resolution, take on a further morbid action. Small points of ul- 
ceration appear on the surface of the patch. These enlarge and unite so 
as to form an ulcer which inay cover the whole of the diseased surface. 
Sometimes, instead of ulcerating at separate points, the mucous membrane 
covering the affected patch sloughs over a larger or smaller area and sep- 
arates from the tissue beneath. If the whole of the patch have been thus 
uncovered, the resulting ulcer is oval, and has its longer axis in the direc- 
tion of the canal. Smaller ulcers may be circular or sinuous. The solitary 
glands may also go through the same process, and leave small, round ul- 
cers scattered over the surface of the mucous membrane. The edges of 
the ulcers are thick and sharply cut, or even undermined ; and the floor 
is formed by the submucous tissue, the muscular coat, or, in bad cases, 
merely by the peritoneal covering of the bowel. 

After a time, a process of repair is set up and the ulcers begin to heal. 
This favourable change seldom occurs before the end of the third week, and 
the process of cicatrization occupies a variable time. Under favourable con- 
ditions it may be completed in two or three weeks, but it is often spread 
over a longer period. The healing of the ulcer is not followed by any con- 
traction of the bowel. 

The morbid process above described attacks especially the glands in 
the neighbourhood of the ileo-caecal valve, and extends upwards for a varia- 
ble distance. In some cases the solitary glands in the ca?cum and part 
of the ascending colon may be also affected. The deeper ulcers are usu- 
ally in the lower part of the iliurn near the valve ; and when perforation 
occurs, it is by rupture of one of these, whose floor is formed only by the 
peritoneal coat of the intestine. That this accident does not occur oftener 
is due to a local peritonitis having been set up, gluing the affected part of 



76 DISEASE IN CHILDREN. 

the bowel to a neighbouring organ. Children who die from this disease 
die almost invariably from perforation of the bowel ; but an unfavorable 
ending to enteric fever is comparatively a rare accident in young sub- 
jects, in whom the unhealthy action in the glands often stops short of 
ulceration. 

Besides the special changes in the glands, the whole mucous mem- 
brane of the bowel is swollen and relaxed. The enlarged mesenteric 
glands seldom suppurate in the child. They usually rapidly undergo res- 
olution as soon as the process of repair has begun in the intestine. The 
spleen is enlarged and congested. It is dark red in color and is softer 
than natural. The kidneys are sometimes congested. In all cases of ty- 
phoid fever the lungs are the seat of catarrh, so that the mucous mem- 
brane of the air-tubes is red and congested, and the bronchial glands are 
enlarged and vascular. 

Symptoms. — After exposure to the contagious poison there is a period 
of incubation varying from ten days to a fortnight, at the end of which 
the symptoms of the fever begin to manifest themselves. These are at 
first very slightly marked ; so much so, that it is sometimes difficult to fix 
the exact time at which the illness began. In most cases, however, careful 
questioning of the parents will enable us to determine the first day of the 
disease. One of the earliest symptoms is frontal headache. Ifc is com- 
mon to be told that a child returned from school saying he had a headache, 
that he looked pale, was languid and could eat no dinner. There is fever 
at this time, but the child, not being sui3posed to be really ill, is not treated 
as an invalid. In other cases headache is not complained of at first. The 
child is merely pale and listless, with some fever, and cannot be persuaded 
to eat. For the first few days little else can be discovered. The tongue 
is coated with a thin, white fur, through which red papillse project. There 
is often slight redness of the throat. The bowels are either confined, or 
one or two loose, rather offensive, stools are passed in the twenty-four 
hours. The child is drowsy, but sleeps restlessly, although without de- 
lirium. He generally complains of his head, and often of aching pains 
about the body and limbs. Sometimes there is vomiting after food, and 
there may be trifling epistaxis. Cough is a more or less constant symp- 
tom, but varies greatly in amount. Usually it is insignificant at the first. 
During this time, unless medical assistance be summoned, the patient is 
seldom confined to his bed, but is dressed in the morning as usual. In- 
deed, in mild cases, children will often walk considerable distances to the 
out-patients' room of a hospital, for the muscular weakness is much less 
marked than might be anticipated. 

So far, then, the symptoms are vague ; and if it were not for the de- 
cided character of the pyrexia, there would be nothing to help us to come 
to any conclusion as to the nature of the illness. It is only at the end of 
the first week that more characteristic symptoms are observed. About 
the sixth or seventh day the spleen begins to enlarge. The organ can be 
felt to project inward towards the middle line from under the cover of the 
ribs. Its texture is soft, so soft, indeed, in many cases, that the enlarge- 
ment can be only detected by a practised finger ; and it appears to be 
tender, for pressure over its substance usually produces some manifes- 
tation of discomfort. Tenderness can generally be noticed at this time 
over the whole belly, and is not confined to the region of the spleen. The 
belly is now a little swollen ; borborygmi are frequent ; and gurgling may 
be often felt on pressure in the right iliac fossa. This, however, is a 
symptom as often absent as present. The bowels are relaxed in the ma- 



ENTERIC FEVER — SYMPTOMS. 77 

jority of cases, although, as a rule, only moderately so, and the stools 
exhibit the yellow ochre "pea-soup" appearance which has been so often 
remarked upon. Still, constipation is a more common phenomenon in 
the child than it is in the adult, occurring in at least one-third of the 
cases. 

The headache now usually subsides, and the patient begins to have 
slight delirium at night. He asks constantly for drink, but seldom shows 
any disposition to take food. His expression at this time is dull and 
heavy, and he lies quietly on his back, often with a dull flush on his 
cheeks, taking little notice of what passes around him. By the end of 
the first week the fever has reached its maximum. The skin, however, 
although generally dry is not always so, and there is occasionally a ten- 
dency to perspiration. The breathing is quickened, and the frequency 
of the pulse is increased. There is no constant relation between the pulse 
and the heat of the body. The pulse may be only moderately quick 
with a high temperature, and its rapidity undergoes frequent variations. 

(Thus, Edith H , aged thirteen, on the eighth day at 9 p.m. : pulse, 86 ; 

respiration, 36 ; temperature, 103.6°. At 9 a.m. on the following morning : 
pulse, 100 ; respiration, 36 ; temperature, 100.8°.) By the end of the first 
week the cough becomes more troublesome, and may assume such prom- 
inence that a lung affection is suspected ; but only dry rhonchus, with per- 
haps an occasional coarse bubble, is heard about the chest. 

After the eighth day the typhoid eruption should appear. In children 
this symptom is sometimes absent ; but careful inspection of the chest, 
abdomen, and back will generally discover a few — it may be only one or 
two — of the characteristic spots. Sometimes they can be detected upon 
the limbs. The rash appears in the form of small, slightly elevated, len- 
ticular spots of a delicate rose tint, varying in size from half a line to a line 
and a half, and disappearing completely under pressure of the finger. 
Their number varies, but they may be very numerous. These spots come 
out in successive crops, each one lasting two or three days. If scanty, they 
have to be searched for with great care, especially when the back is examined, 
for here, on account of the general congestion of the surface, they may not 
be readily seen. 

In this the second week of the illness as each day passes the child seems 
to become duller and more indifferent. He is drowsy and sleeps much 
during the day, but at night may be more restless, and sometimes he tries 
to leave his bed. His weakness has now become more marked. The pulse 
is quick and feeble ; and towards the end of the week muscular tremors 
and twitchings may be noticed. The belly is much swollen and assumes 
the characteristic barrel shape. The looseness of the bowel continues, or 
is replaced by constipation, and sometimes — although this is rare in the 
child — the motions contain blood. At this time the heart-sounds become 
feeble and soft to the ear, and there is often a prolongation of the first 
sound at the apex, or even a soft systolic murmur. On the other hand, in 
old standing cases of cardiac disease a murmur previously heard may be 
lost as the heart's action becomes enfeebled, only to reappear when the 
strength is restored. 

In the third week of the illness the fever usually begins to diminish. 
In the mild cases the temperature becomes natural as early as the fourteenth 
day. If it persist, its mean is lower than before, and the morning tem- 
perature may be almost normal. The feebleness of the patient is now 
sufficiently pronounced, but as the days pass by his symptoms become 
more favourable. He grows less heavy and lethargic ; the swelling of his 



78 DISEASE IN CHILDREN. 

belly diminishes ; the spleen retires under the ribs ; diarrhoea, if it had 
previously existed, ceases, and the motions become more natural ; and as 
the tongue cleans, the child begins to show some dissatisfaction at being 
still restricted to liquid food. As the fever subsides, the pulse often be- 
comes intermittent, and is very soft and compressible. When the fever 
is at an end the child is left very weak in the mildest cases, and he only 
slowly regains his strength. In bad cases the prostration is very great, and 
the child has to be nursed through a protracted period of convalescence.' 
Sometimes oedema, more or less general, is seen as a consequence of the 
impoverished state of the blood. 

The above is a sketch of the ordinary course of enteric fever in the 
child. There are, however, many variations in the symptoms, and it is 
desirable therefore to refer again to some of the principal phenomena. 

Tlie Digestive Organs. — The tongue in mild cases remains moist through- 
out the whole course of the illness. It has a delicate coating of grayish 
fur, through which the papillae are seen to project. The tip and edges are 
only moderately red. Thirst is often a marked symptom, and liquid food 
is taken readily to satisfy this craving for fluid. Appetite is generally lost, 
but not in every case. A little boy in the East London Children's Hospital 
complained to me on the sixth day of the disease that he was hungry, 
although his temperature was then 105°, and his tongue was thickly furred, 
with sordes on the lips. His mind was quite clear. If the symptoms are 
severe the tongue generally becomes dry in the course of the second week. 
It may be fissured across the dorsum, and the lips may be cracked and 
blackened. Sore throat is a very common symptom during the first few 
days, and there is some little redness of the fauces. Vomiting is frequent 
at the beginning ; occasionally it recurs later and may then give trouble. 

The swelling of the abdomen is due to accumulation of flatus through 
decomposition of food and inability of the bowels to expel their gaseous 
contents. This loss of contractility is the consequence of lack of nerve- 
power or of local injury from ulceration. Consequently, if in the third 
week of illness there is deep ulceration of the intestine and great bodily 
prostration, the distention of the belly may be extreme. The amount of 
abdominal tenderness varies. In the mildest cases it may be absent. When 
present it may be local, limited to the splenic region and the right iliac 
fossa, or may be general over the abdomen. It is sometimes a well-marked 
symptom, the slightest touch being productive of great pain, and this in 
cases where there is no reason to suspect the presence of peritonitis. The 
bowels may be confined throughout, or loose throughout, or constipation 
may alternate with a mild diarrhoea. It must be remembered that loose- 
ness of the bowels is due not to the ulceration but to coexisting catarrh. If 
catarrh be insignificant or absent, the bowels are not relaxed. As a rule, in 
children the looseness is not extreme and is easily controlled. The relaxed 
motions always assume at one time or another the "pea-soup" character; 
they have an alkaline reaction and a faint offensive smell. Haemorrhage 
from the bowels to any amount is rare, but small black clots of blood may 
be sometimes found in the grumous matter at the bottom of the stools. 

The urine is at first scanty, with a high density. It contains an excess 
of urea and uric acid, but is poor in chlorides. Later it becomes more 
copious, the specific gravity falls, and it may contain a trace of albumen. 
During the height of the fever there may be retention of urine, with dis- 
tention of the bladder and tenderness over the pubes. Sometimes the 
catheter has to be employed. There is no gravity about this symptom, 
and it need cause no anxiety if care be taken to empty the bladder by 



ENTERIC EEVEPw — SYMPTOMS. 79 

degrees. The distention is due to loss of contractile power of the muscu- 
lar coat. If, then, a greatly distended bladder be suddenly and com- 
pletely emptied of its contents, the organ contracts imperfectly, and a cer- 
tain amount of air enters and causes great irritation. An obstinate cystitis 
may be produced in this way. 

The jwlse is quick as a rule, but sometimes for a time sinks in rapidity 
although the fever continues high. The frequency of the pulse is not, as 
has already been stated, any trustworthy guide to the degree of fever ; nor, 
as taken at a single examination, is it necessarily any test of the severity 
of the illness. 

The respirations are hurried, and there may be slight disturbance of 
the normal pulse-respiration ratio without any pulmonary complication 

being present. (Thus John H , aged four years, sixth day, 4 p.m. : 

temperature, 103°; pulse, 120 ; respiration, 46). If a pulmonary complica- 
tion actually arise, the breathing increases in rapidity and there is lividity 
of the face. 

The skin may be moist at times during the course of the disease, and 
towards the end of the third week, especially if the fever has subsided, 
there may be copious sweating. Sudamina then appear on the chest. 
The abundance of the rash varies greatly in different cases. It may be 
very copious or completely absent ; but these extremes bear no relation to 
severity or mildness of attack. It is well to be aware that fresh crops of 
rose-spots may continue to appear for a week after the temperature has 
fallen to the normal level. I have noticed this on several occasions. The 
facies is important. The child seldom looks very ill in the early stage ; 
and even later, unless the abdominal mischief be severe, it is exceptional 
for his face to wear the anxious haggard look which is so common in many 
other serious diseases, and forms such a striking feature in acute tubercu- 
losis. In ordinary cases the expression is more stupid and listless than 
anxious. 

The special senses may be affected. Deafness is common. Epistaxis 
is a frequent symptom, and may be repeated again and again. The con- 
junctivae look red, and the pupils are large. The headache in children is 
seldom very severe. It ceases about the end of the first week, when the 
delirium begins. Sometimes cervical neuralgia is noticed after the second 
week, and every movement of the neck may be accompanied by pain. De- 
lirium is the rule, beginning towards the end of the first week. Some- 
times from this cause older children try to get out of bed and are noisy. 
Convulsions may precede death in fatal cases ; but typhoid fever, unlike 
many other febrile complaints in childhood, is very rarely ushered in by a 
convulsive attack. Still, a form of disease is usually described in which 
the early symptoms are those of high nervous excitement. The child is 
convulsed and has marked delirium. I have never met with a case of this 
form of typhoid fever in a young subject. 

The pyrexia, like most forms of febrile movement in the child, is re- 
mittent, but the degree of remission varies at different periods of the dis- 
ease. In the second week there is, as a rule, less variance between the 
maximum and minimum temperatures than at an earlier or a later stage of 
the complaint. To test the bodily heat with any exactness, the tempera- 
ture should be taken every three or four hours, both day and night. Very 
false conclusions may be drawn from a merely diurnal use of the ther- 
mometer, for the mercury is not necessarily at its lowest point at 8 or 9 
a.m., nor at its highest at 6 or 7 o'clock in the evening. Again the mini- 
mum temperature may be non-febrile, or even subnormal. (Thus, in the 



80 DISEASE IN CHILDREN. 

case of Lilly F , aged eleven years, a patient in the East London 

Children's Hospital, the temperature during the morning hours from 8 
o'clock to noon was subnormal after the ninth day. It was often as low 
as 97°, and yet this was an undoubted case of typhoid fever. In the even- 
ing the heat was 102° or 103°.) It is difficult to lay down a rule in a 
matter which is subject to such endless variety ; but perhaps the minimum 
temperature is reached more often between the hours of 10 a.m. and noon 
than at any other time, and the maximum shortly before midnight or in 
the early morning hours. In the third week of the disease the remissions 
generally become very marked, and the minimum registered is often little 
higher than a normal temperature. This is especially noticeable towards 
the end of the week. 

During the first few days of the fever it is rare for the child to be under 
skilled observation, and a record of the temperature at this time is not 
easy to obtain. Occasionally, however, a hospital patient, admitted for 
some chronic complaint, sickens of the disease. Such a case occurred 
lately in a little girl, aged nine years, who was being treated for hip-joint 
disease in the East London Children's Hospital by my colleague Mr. 
Parker, and was transferred to my care on the outbreak of the fever. The 
child, whose temperature had been normal, complained of headache at 2 p.m. 
Her temperature was then found to be 102.6°. At 10 p.m. it had fallen to 
100°. On the second day, at 6 a.m., it was 99° ; but rose gradually, being 
taken every four hours, till 6 p.m. when the thermometer marked 103.2°. 
It then fell suddenly to 99° at 10 p.m. On the third day at 10 a.m. it was 
102.4° ; at 2 p.m., 102.4° ; at C p.m., 101.8° ; at 10 p.m., 102.6°. After this 
it varied between 101° and 103.8° in the twenty-four hours, until the 
middle of the third week when it rose rather higher. 

In a case kindly communicated to me by my friend Dr. Gee, the tem- 
perature in a little girl under his care was 103° on the first day at 2 p.m., 
and at 10.30 p.m. it was 103.6°. 

In a case published by Dr. Ashby, of Manchester — a little girl of nine 
years — the temperature was 100° on the first evening. On the second 
day: morning, 99.4°; evening, 101.8°. On the third day: morning, 
100.4° ; evening, 100.4°. Fourth day : morning, 101° ; evening, 103.4°. 

From these three cases it appears that there may be great variations in 
the degree of pyrexia at the beginning of the disease. In my own case 
the temperature reached its height on the second day at 6 p.m. ; but dur- 
ing the first two days the variations were very great. 

The duration of typhoid fever is from fourteen to twenty-six * days as a 
rule. The temperature often falls in young subjects at the end of a fort- 
night ; and sometimes, although very rarely, may become normal at a still 
earlier date. The possibility of so short a duration for the fever has been 
doubted, but that it may occur is proved by the following case. 

A little girl, aged nine years, was perfectly well on September 14th. 
On the following day, the 15th, she complained of chilliness and frontal 
headache. That night the skin was noticed to be hot, and for the next 
week the child was apathetic, languid, and feverish, complaining of head- 
ache and abdominal pain. She did not vomit, and there was no bleeding 
from the nose. The child was seen on the 22d. Her temperature was 
then 102°, and a rose-spot was noticed on the abdomen by the house 
surgeon. On the 23d (ninth day) she was admitted into the hospital. 
The abdomen was then moderately distended ; the spleen could be felt two 
fingers'-breadth below the ribs ; no spots were to be seen ; the temperature 
in the evening was 102.6°. 



ENTERIC FEVER — PERFORATION. 81 

After this date the temperature was never higher than 99° and a fraction ; 
the child looked and expressed herself as well ; the spleen quickly retired 
under the ribs ; the appetite was good, and the patient complained much 
at being restricted to liquid food. On October 5th, the temperature having 
baen normal for twelve days (with the exception that on one occasion, in 
the course of September 27th, it rose to 100.3°), and subnormal for six, 
the child was put on ordinary diet. Two days afterwards the temperature 
rose to 102°, the spleen began to enlarge ; rose spots appeared on the ab- 
domen ; and the patient passed through a well-marked relapse of typhoid 
fever which lasted the usual nine days. 

In this case the early cessation of the pyrexia seemed to exclude typhoid 
fever ; and as the temperature continued low, a meat diet was allowed 
under the idea that our first impression of the illness had been a mistaken 
one. The prompt occurrence of a typical relapse, however, at once re- 
moved our doubts as to the nature of the primary attack. 

In some cases the temperature remains high after the usual time of fall- 
ing at the end of the third week. In many cases this is due to progressive 
ulcerative enteritis. Indeed, Dr. Gree lays it clown as a rule that when 
pyrexia and enteric symptoms last longer than twenty-six days this is the 
cause of the prolongation of the disease. He also suggests that "subin- 
trant relapse " may be an occasional agent in producing the same result. 

Death from the intensity of the general disease, so common in the 
adult, is very rare in early life. In very exceptional cases, however, the 
diarrhoea may be excessive ; the temperature may rise to a high level ; the 
pulse may be frequent, feeble and dicrotous ; the abdomen may be 
swollen and tympanitic ; the child is delirious, then comatose, and dies 
with a temperature of 108° or 109°. Still, although this type of the 
disease is occasionally met with in the child, it must happen to few prac- 
titioners to meet with such cases. When children die from typhoid fever, 
they die almost invariably from perforation of the bowel and general peri- 
tonitis. The rupture occurs in the floor of a deep ulcer and takes place 
quite suddenly. It is followed by an escape of gas and of the fluid con- 
tents of the intestine into the peritoneal cavity. Immediately, the abdo- 
men becomes distended, and there is intense pain and tenderness. Some- 
times there is vomiting, but the patient in any case sinks into a state of 
collapse with dusky haggard face, cool purple extremities, and small rapid 
pulse. Although the surface of the body feels cool, the internal heat re- 
mains high (103-104°). The respiration is thoracic. According to Nie- 
meyer, sudden disappearance of the liver dulness, on account of that 
organ being separatee! by the tympanitis from the abdominal wall, is one 
of the most certain signs of peritonitis from perforation of the bowel. 
This accident does not often happen before the end of the third week. 
When the peritonitis is general, it is almost invariably fatal, and death is 
sometimes preceded by an attack of convulsions. If the intestine have 
been previously matted by local inflammation, rupture of the floor of the 
ulcer may not lead to such serious consequences. In such a case when 
perforation occurs, the extravasated contents of the bowel remain encysted, 
and the resulting peritonitis is limited to the neighbourhood of the lesion. 
In the end the abscess thus formed generally makes its way to the surface 
and discharges its contents at some point of the abdominal wall. 

Other complications which give rise to discomfort or danger are : — 

inflammation of the parotid gland, or of the middle ear, bronchitis, pleurisy, 

pneumonia, and catarrhal pneumonia. In one case— a boy aged thirteen, 

under my care in the East London Children's Hospital — an extensive 

6 



82 DISEASE m CHILDBED. 

plastic pericarditis arose during the third week of illness. Bedsores 
rarely occur unless the child is greatly reduced by protracted illness ; but 
boils and abscesses are not uncommon. Ulceration of the larynx has been 
described, but must be very rare. Another rare complication is throm- 
bosis of the veins of the lower extremities. 

After the fever has subsided, the temperature usually remains subnor- 
mal for some time. Not unfrequently, however, after the lapse of a few 
days, the child is noticed to be feverish again. These secondary pyrexias 
are very common. They may be due to a real relapse ; to the presence 
of some irritant in the bowel, such as hardened fecal matter or undigested 
food ; or to some febrile complication which may be called accidental, as 
an abscess. 

Keal relapses are far from uncommon. They begin after a variable in- 
terval — four or five days, or longer — and seem in many cases to be deter- 
mined by injudicious feeding in the stage of early convalescence. The 
temperature rises ; the spleen again enlarges ; fresh spots appear ; and the 
bowels may be again relaxed. Usually the symptoms are milder than in 
the primary attack and last a shorter time. The average duration of a re- 
lapse is nine days. 

Constipation and the irritation of the bowel by hard fecal masses is a 
common cause of secondary pyrexia. The temperature usually rises to 
102° or 103°, but may be higher. When the irritant has been removed by 
a copious injection, the pyrexia at once disappears. These attacks of tem- 
porary elevation of temperature may recur again and again in the course 
of convalescence, but need occasion no anxiety. 

Convalescence from typhoid fever is often tedious. The child is left 
weak and low, and nutrition may not at once be re-established. It is a re- 
markable fact — to Avhich attention has been drawn by Dr. West — that the 
patient is enfeebled intellectually as well as physically by his illness. For 
some weeks after the fever is over he may remain dull and indifferent, 
taking little interest in pursuits and amusements which formerly delighted 
him. A child of three or four years of age may seem to have forgotten 
how to talk ; and the persistence of this mental weakness for some time 
after the strength has been restored is often a cause of great anxiety to the 
patient's friends. Such anxiety is, however, groundless, for the return of 
mental tone at no long interval may be confidently predicted. 

These cases appear to be due sometimes to defective action of the kid- 
neys. In one case which came under my notice the child (a boy of seven) 
was left after typhoid fever in an apathetic, stupid condition, taking no 
notice of anything, and never speaking even to make known his natural 
wants. He appeared to be in a state of great weakness, and had occasion- 
ally nervous seizures in which he became quite stiff, and seemed to be un- 
conscious. His skin was dry and excessively inelastic ; there was no dis- 
coverable disease of any of his organs ; his temperature was subnormal. 
At first he had a slight trace of oedema of the legs, but this quickly passed 
off. His urine never contained albumen, but its quantity was small. For 
a loug time the boy passed no more than ten or twelve ounces in the 
twenty-four hours, with a specific gravity of 1.015. The excretion of solid 
matter by the kidneys was so evidently deficient that diuretics were or- 
dered, and the boy was forced to take a larger quantity of fluid. Under this 
treatment he soon began to mend ; his urine became more copious with a 
higher density ; the elasticity of his skin returned ; his nervous seizures 
ceased ; and his strength, mental and bodily, rapidly improved. 

A child with any diathetic taint may have his predisposition strength- 



ENTERIC FEVER — DIAGNOSIS. 83 

ened by his illness. Tuberculosis sometimes occurs ; and scrofulous ten- 
dencies may receive a distinct impulse. 

Diagnosis. — On account of the negative character of the symptoms at 
the beginning of the illness, enteric fever is often difficult to recognize in 
the early stage ; and even at a later period the nature of the complaint 
must be sometimes a matter of doubt. Still, the disease is one of such 
frequent occurrence that we should always remember the possibility of its 
being present, and should never omit in a doubtful case to make inquiry 
as to the existence of the disease in the neighbourhood. The beginning of 
measles, scarlatina, and variola is sufficiently distinctive to prevent their 
being confounded with this disorder, and moreover, the absence of the 
specific eruptions of these complaints will serve for their exclusion. A 
high temperature on the second day in a child who suffers from nothing 
but an ill-defined malaise is enough to give grounds for suspicion. If, as 
the days pass, no other symptom develops itself, our suspicions are ma- 
terially strengthened ; and when at the end of the week, enlargement of 
the spleen with swelling and tenderness of the belly can be detected, 
especially if there is also looseness of the bowels, there is hardly room for 
further hesitation. # 

Acute tuberculosis may present a very close resemblance to enteric 
fever in the child, especially as we sometimes see a rose spot here and 
there on the bodies of tubercular children which, except for being rather 
larger than the typhoid spot, and perhaps a little less delicate in colour, 
may be, and indeed has been, mistaken for it. In both tuberculosis and 
enteric fever diarrhoea may be a prominent feature ; in both there is fever ; 
and in both the general symptoms may be very indefinite. Often, in these 
cases we cannot decide, but must wait for time to relieve our uncertainty. 
But in many cases we may venture upon an opinion, for in tubercu- 
losis the absence of any definite time of beginning ; the less elevated tem- 
perature, the bodily heat being rarely higher than 101° in the evening ; the 
distressed expression of the patient ; the absence of inflation of the abdo- 
men, and the natural size of the spleen are all points in which that form of 
illness differs from typhoid fever, and may serve to help us to a conclusion. 

Sometimes enteric fever may be mistaken for tubercular meningitis. 
The illness may begin with drowsiness and sickness ; the headache may be 
severe and provoke cries from the child such as are common in the intra- 
cranial inflammation ; the vomiting may persist, and the bowels may be 
obstinately confined. Still, the belly is distended, and has not the doughy, 
flaccid condition of the parietes so peculiar to tubercular meningitis ; the 
pulse, "until convalescence begins, is not slow and intermittent ; the respi- 
ration is not sighing ; the pupils do not become unequal, and there is no 
squint. The temperature, too, is much higher in the case of typhoid fever, 
for in the earlier stages of tubercular meningitis the bodily heat is seldom 
greater than 101°. Later, none of the symptoms of the third stage of tuber- 
cular meningitis can be discovered. 

Acute gastric catarrh, accompanied as it is in scrofulous children with 
pyrexia, may cause some embarrassment, but here the temperature is less 
high than in enteric fever, and does not undergo the same alternations ; 
there is no distention of the abdomen, and no enlargement of the spleen. 
Still, in many cases, before the fever subsides on the ninth or tenth day, 
we cannot say positively that we have not to do with the more serious 
disease. 

When the purging is severe the case maj' be confounded with one of 
inflammatory diarrhoea, and it is possible that in young children under 



84 DISEASE IN CHILDREN. 

three or four years of age the mistake is often made. I think, however, 
that the shorter course of a non-specific muco-enteritis, the severity of the 
purging from the first, the haggard aspect of the patient, and, if the dis- 
ease last long enough, the absence of splenic enlargement, of the rosy rash, 
and of the signs of pulmonary catarrh, should be sufficient to furnish a 
distinction. 

Simple or tubercular ulceration of the bowels with enlargement of the 
mesenteric glands may be also mistaken for enteric fever. But in these 
disorders the temperature is less elevated than in typhoid fever, and the 
history of the illness is very different. Their course, also, is very much 
longer. There is, besides, absence of the rash, of the splenic enlargement 
(unless, as may happen, there is tubercular disease of the spleen) and of 
the signs of pulmonary catarrh. Further, in tubercular ulceration the 
lungs are generally the seat of consolidation and the emaciation is extreme. 

Chronic tubercular peritonitis, with its rough harsh skin, its pseudo- 
fluctuation, and the caseous masses to be felt on palpation of the abdomen, 
can scarcely be confounded with enteric fever. 

Lastly, the distinction between typhoid and typhus fevers is now suffi- 
ciently established. In the latter disease the onset is. always abrupt, the 
rash, abundant and quite different in its appearance from the rosy typhoid 
spots, appears on the fifth day ; the face is dusky ; drowsiness and stupor 
are early symptoms ; and the end — whether favourable or the reverse — 
comes in a sudden crisis. 

Prognosis. — It has been already said that comparatively few children 
die from this disease ; but small as is the percentage of mortality, it is 
greater than it need be. This is partly due to the way in which the 
disease begins, and the mildness of its early symptoms making diagnosis 
doubtful. It is also owing in part to the character of the early symptoms, 
and the abuse of domestic remedies. A child is found to be poorly ; he 
vomits and complains of headache. Immediately he is treated to a dose 
of castor-oil or other aperient ; and as the symptoms are not found to 
be relieved by this measure, the dose is repeated, perhaps several times. 
There is no doubt that such treatment is excessively injurious ; and in 
hospital practice the cases which terminate fatally generally have a history 
of active purgation having been adopted before admission. 

However severe the symptoms may be, we may look forward hopefully 
to the issue provided perforation has not occurred. Children respond 
well to stimulants in typhoid fever ; and a patient who is seen stupid 
and drowsy and profoundly depressed on one visit, may present a very 
different appearance on the next under the free use of brandy. I think 
even muscular tremors have not the same unfavourable meaning in the 
child that they have in the adult. Still, if the tongue quivers when pro- 
truded, the lower jaw trembles when the mouth is open, and general 
tremulousness of movement is pronounced, we have reason to fear the 
presence of a deep ulcerative lesion in the intestine. Our apprehensions 
are strengthened if at the same time the belly is much distended, and the 
temperature remains persistently elevated after the end of the third week. 
In such a case the danger of perforation is imminent. 

If perforation take place, the prognosis is most grave ; but even in 
this strait death is not absolutely certain. If the collapse which follows 
the extravasation be quickly recovered from, even although considerable 
tympanitis, pain, and tenderness remain, we may hope that the peritonitis 
has been localised by intestinal adhesions, and that further improvement 
may take place. 






ENTERIC FEVER— TREATMENT. 85 

Treatment. — In every case of typhoid fever, if there is any reason to 
suppose that the disease has been contracted in the house, the drains 
should be thoroughly examined at the earliest opportunity, and every care 
must be taken to prevent the entrance of sewer-gas into the passages. 
All soil-pipes should be ventilated: waste-pipes should be cut off from 
direct communication with the sewers ; cisterns supplying water for 
drinking and cooking should be entirely separated from those whose pur- 
pose is merely sanitary ; and the water itself — unless its purity be above 
suspicion — should not be drunk without having previously been boiled 
and filtered. 

The treatment of typhoid fever consists mainly in careful and judicious 
nursing. Sir William Jenner has insisted strongly upon the absolute 
necessity in this complaint of perfect rest. The child should be confined 
to bed at once, and if the attack has occurred at a distance from his home, 
it is better that he should remain where he is, than run the risk of in- 
creasing the severity of his illness by the fatigues of a removal. Fatigue 
not only exhausts nerve-power, which is already reduced by the fever, but 
it also increases destruction of tissue at the same time that it checks elimi- 
nation by the excretory organs. The bedroom should be a large one, and 
the air must be kept as pure as possible by judicious ventilation. Its 
temperature should not be allowed to rise above 65°. The patient should 
be lightly covered and not overloaded with bedclothes. There is, how- 
ever, one precaution which it is expedient to take. As in all cases where 
the mucous membrane of the bowels is the seat of catarrh, flannel in the 
shape of a flannel bandage should be applied round the belly so as to 
avoid the risk of chill. All discharges from the body must be at once 
disinfected before being removed from the room, and linen, etc., soiled by 
such discharges must be subjected to the same disinfecting process before 
being washed. If there be reason to suspect the purity of the water-sup- 
ply, none should be used for drinking purposes without previous boiling 
and filtering. This, however, the child may be allowed to drink without 
stint, provided too large a quantity be not taken at once. A free supply 
of water assists the depurating action of the skin, kidneys, and lungs ; but 
distention of the stomach by too much fluid is provocative of nausea and 
flatulence. For this reason effervescing drinks are to be avoided ; they 
are apt to distend the stomach and cause uneasiness. 

The question of diet is a very important one. The old plan of " starving 
the fever " and reducing the patient has been fortunately abandoned, but 
we must not fly to the opposite extreme and overload the stomach with 
food in the hope of supporting the strength, however digestible and well 
selected the food may be. Farinaceous matters, on account of their ten- 
dency to ferment and form acid, are better avoided. Fruit for the same 
reason is out of the question. It is better to restrict the diet to meat 
broths made fresh in the house, and to milk. The broths may be flavoured 
with vegetables, but must be carefully strained. The milk should be di- 
luted with an equal quantity of barley-water, so as to split up the curd and 
prevent its coagulating in the stomach in large lumps. Masses of hard 
curd are a frequent source of irritation, and may excite restlessness and ab- 
dominal pains. They may also, perhaps, increase the diarrhoea. The 
quantity of food to be given at one time should never be left to the dis- 
cretion of the attendants. Nourishment should be administered in pre- 
scribed doses at regular intervals — the quantity and the length of the in- 
tervals to be decided by the age of (he patient and the facility with which 
the meal can be digested. Nausea, restlessness, excitement of pulse, in- 



86 DISEASE IN CHILDEEN. 

crease of fever, and flushing of face, are signs that the digestive organs are 
being taxed beyond their powers. 

The question of stimulation is closely allied to that of food. Stimu- 
lants must not be given too early. They are useful to strengthen the ac- 
tion of the heart and increase nerve-energy, but are seldom required before 
the end of the second or beginning of the third week of the disease. Even 
then, they should be only given in severe cases where the heart's action 
gives signs of failing, and there is marked delirium or great muscular pros- 
tration with tremor. Tremor, " out of all proportion to other signs of 
nervous prostration," is, in the opinion of Sir William Jenner, evidence 
of deep destruction of the bowel. In these cases alcohol is of the utmost 
value. The signs connected with the heart which may be taken to indicate 
the necessity for stimulation are diminution or suppression of the impulse 
with feebleness of the first sound. The effect of stimulation should be 
carefully watched. If the fever diminish, the tongue and skin get or re- 
main moist, the pulse and respiration become slower and fuller, and the 
mind clearer, we may know that we have benefited our patient. If, on the 
contrary, the temperature rise, the heart's action become feebler and more 
frequent, the delirium increase, and the child get restless w T ith inability to 
sleep ; or if he become duller and seem sinking into a comatose state, we 
may conclude that alcohol is acting injuriously, and that it must be discon- 
tinued or given in smaller quantities. 

In typhoid fever, as in all other febrile diseases, it is important to 
watch the temperature and regulate it. If, for instance, with a tempera- 
ture of 105°, w<e find restlessness and excitement with wakefulness, the 
child should be sponged over the whole body with tepid or cold water. 
This lessens fever, calms irritability, and induces sleep. More than tepid 
or cold sponging is seldom necessary. If, however, the temperature be 
not appreciably lowered by the sponging or rise again immediately, the 
child may be placed gently in a bath containing water at 70°, and be kept 
immersed for ten, fifteen, or twenty minutes. It is w r ell to continue the 
bath until distinct shivering has been produced. The child must be then 
removed, wiped dry, and returned to his bed. A stimulant may be given 
at this time if thought desirable. The cool bath should not be used unless 
there is a real necessity for it. Children can bear a continued high tem- 
perature better than older persons ; and if there is a daily remission, as 
occurs in most cases, mere sponging will do all that is required. 

Delirium is scarcely sufficiently violent in children to require treat- 
ment — at any rate in ordinary cases, and headache is seldom a trouble- 
some symptom. If it should be so, it is usually relieved by cold applica- 
tions. Sleeplessness may be generally relieved by the tepid sponging 
above referred to. If necessaiw, a draught containing bromide of potas- 
sium in combination with chloral may be given. 

Diarrhoea may sometimes require remedies. In every case where the 
stools are too frequent and watery we should examine them for curd of 
milk. If this be present, the amount of milk taken at one time must be 
reduced. We should also take care that the child does not drink fluid in 
excess, and if necessary his drink must be given to him in smaller quan- 
tities. "When drugs are required to arrest the purging, chalk and catechu 
should be given if the motions are frothy. If they are strongly alkaline, 
dilute sulphuric acid is most useful. In the later period, w T hen there is 
ulceration of the bowel, bismuth in large doses is indicated. Haemorrhage 
from the bowels is a comparatively rare symptom in the child and seldom 
requires treatment by drugs. If necessary, however, gallic acid and dilute 



ENTERIC EEVER — TREATMENT. 87 

sulphuric acid may be administered with small doses of opium. In such 
a case the child should on no account be allowed to raise himself from 
the recumbent posture even to relieve the bladder or the bowels. It is 
well also to give him his food in small quantities and in a concentrated 
form. Strong beef-essence, well iced, and good meat jelly should be em- 
ployed ; and but little milk should be allowed, for fear of irritating the 
intestine with lumps of curd. 

If perforation and peritonitis occur, opium should be given in small 
doses, but frequently, so as to produce some of the early physiological 
effects of the drug, such as drowsiness and tendency to contraction of 
pupils. In my experience opium is in such cases of small value unless 
pushed to this extent. The belly should be also smeared with an oint- 
ment composed of equal parts of extract of belladonna and glycerine, and 
be kept covered with hot linseed meal poultices frequently renewed. The 
food in these cases also must be concentrated and given frequently in small 
quantities. Brandy and egg will be required to sustain the strength. 

Daring the period of convalescence careful feeding is still necessary, 
for errors in diet at this time are a frequent cause of relapse in the fever. 
I have always made it a rule to allow no solid food until ten days have 
passed after the final fall of temperature. But even then the usual diet 
of health should be only slowly returned to. 

In order to prevent relapses Immerman recommends, in addition to 
the utmost vigilance with regard to diet, the daily administration of sali- 
cylate of soda in full doses; beginning directly the fever subsides, and 
continuing the use of the drug for ten or twelve days. The after anaemia 
and weakness must be combated by iron and good food. Change of air 
to a dry bracing place or to the seaside is very useful 



CHAPTER X. 

DIPHTHERIA. 

Diphtheria is an acute contagious disease which, on account of its pre- 
valence, its gravity, its consequences, and the frequency with which it is 
met with in the child, takes a prominent place amongst the disorders of 
early life. The disease induces great anaemia and prostration, and is 
characterized anatomically by inflammation of various mucous surfaces and 
the formation on them of a more or less tough and leathery false mem- 
brane. The inflammation often spreads to some distance from its point 
of origin, but at first is usually confined to a comparatively limited area. 
The seat varies in different cases ; and the symptoms are therefore subject 
to great variety according to the part in which the chief local expression 
of the disease occurs. 

When the inflammatory process attacks the larynx the malady is called 
membranous croup, and this was long held to be a distinct affection. 
Whether all cases of membranous croup are diphtheritic in their nature 
— whether a false membrane can be developed in the air-passages apart 
from the diphtheritic poison — is a question upon which pathologists in this 
country are still divided. That membranous croup arises in many cases 
from this cause is undeniable. Instances have been met with in which diph- 
theria has attacked the pharynx in some members of a family and the 
larynx in others. Thus, Dr. Woodman found membranous laryngitis in 
two infants, aged respectively eighteen months and two months, while 
others of the family suffered from false membrane in the mouth and 
pharynx. Dr. Wilks has seen in different inmates of the same house the 
disease remain confined to the throat, or spread thence to the larynx, or 
begin in the larynx ; and Trousseau refers to a case reported by Dr. A. 
Guerard in which a little girl died of laryngeal croup, and other members 
of the family suffered immediately afterwards from pseudo-membranous 
pharyngitis. Moreover, it is admitted by the best authorities that the 
laryngeal false membrane has exactly the same anatomical characters, 
whether it be due to the spread of a pharyngeal diphtheria or arise pri- 
marily as a case of membranous croup. 

Advocates of the essential difference between the two forms of illness 
maintain that the character of the two diseases is not the same. Croup, 
they say, is a sthenic disease, while diphtheria is asthenic. But some 
cases of croup are accompanied by severe constitutional de23ression and all 
the signs of profound general disease ; while diphtheria is not invariably 
accompanied by symptoms of prostration. Indeed, one of the peculiari- 
ties of this affection is the occurrence sometimes of marked paralysis after 
an attack of sore throat so mild as to be almost overlooked. 

Secondly, it is pointed out that in diphtheria the glands at the angles 
of the jaw are invariably enlarged, while in membranous crouj) they are 
little if at all affected. But the larynx has little connection with the su- 



DIPHTHERIA AND CROUP. 89 

perficial cervical glands. As Dr. Morell Mackenzie has pointed out, in 
cancer of the larynx the cervical glands are not enlarged, while if the 
malignant disease affect the pharynx these glands are always involved. 

Thirdly, the contagiousness of diphtheria is insisted upon, while mem- 
branous croup is said not to be communicable by one child to another. 
But the risk of infection is in direct proportion to the amount of exuda- 
tion, and the readiness with which the membrane can be detached and 
dispersed. In the glottis the membrane is very firmly adherent ; in the 
pharynx its connections are much looser, and it is much more easily 
separable from the mucous surfaces. Moreover, as Sir William Jenner has 
observed, the conditions in which the patient is placed vary greatly in the 
two cases. A child with diphtheria in its early stage is up and about, kisses 
his brothers and sisters, and has every opportunity of conveying the dis- 
ease to them. A patient with membranous croup is kept in bed apart from 
the other children and carefully tended. Still, there is strong evidence 
that, in spite of these hindrances to its ready communication, membranous 
croup may be conveyed from one child to another. Dr. Trend states that he 
has seen the laryngeal disease in more than one child of a family at the 
same time. Dr. Wilks believes that he has seen diphtheria begin in the 
house as a case of supposed membranous croup, and afterwards attack 
others of the inmates in the form of diphtheritic pharyngitis. Dr. A. 
Guerard's case, already referred to, is another instance of the contagious- 
ness and interchangeability of the two varieties. 

Fourthly, albuminuria, which is common in diphtheria, is said to be 
rare in membranous croup. But this is not altogether the fact. More- 
over, albumen does not always appear in the urine at the beginning of an 
attack of diphtheria, but may be delayed for several days. Now the dura- 
tion of fatal cases of croup is often terribly short ; so that the patient may 
die before the albuminuria has had time to occur. 

Lastly, paralysis is a not uncommon sequel of diphtheria, while in 
membranous croup it is very rare. But it must be remembered that true 
membranous croup is an excessively fatal disease and comparatively few 
cases recover. Even as a consequence of diphtheria the occurrence of par- 
alysis is variable in different epidemics ; and taking the milder cases with 
the severer, the proportion has been estimated by Dr. Greenfield at no 
more than one in twelve. In convalescents from membranous croup the 
proportion who are likely to suffer from paralysis would, therefore, under 
any circumstances be very small. 

From consideration of the above facts and arguments the only conclu- 
sion to be drawn is that a large proportion of cases of membranous croup 
are cases of laryngeal diphtheria. It does not, however, follow that mem- 
branous laryngitis is never due to any other cause than the diphtheritic 
poison. The child's larynx is especially prone to membranous inflammation ; 
and if, as has been positively stated, a true false membrane may be set 
up by burns, scalds, and other irritants to the air passages, it is possible 
that the disease may occasionally occur independently of the diphtheritic 
virus. 

Diphtheria is met with both as an epidemic and as an endemic disease, 
and varies much in character and severity at different times and in differ- 
ent localities. It may attack children who are apparently in robust health, 
may arise in cachectic subjects, or appear as a sequel of severe general dis- 
ease. Like typhoid fever the disorder is apt to occur more than once in 
the same individual, for the protection it affords against a recurrence is 
by no means complete. Sometimes the second illness may be more severe 



90 DISEASE IN CHILDREN. 

than the first, for a child who has passed safely through one attack may 
succumb to a second. 

Causation. — On account of the susceptibility to diphtheria in early life, 
childhood may be considered to be one of the predisposing causes of the 
malady. Infants under twelve months of age are not often attacked ; but 
after that age and up to the fifth or sixth year the disease is frequently 
met with. After the sixth year it again becomes less common, and is com- 
paratively rare in the adult. Besides this natural susceptibility, there is 
probably in many cases a special susceptibility inherent in the constitution 
of the patient. Sometimes whole families are cut off during an epidemic 
of the distemper. Sometimes successive children of the same parents fall 
victims to the disease at various times and in different places ; and in many 
cases this unfortunate predisposition appears to be a hereditary defect. 
Besides these general causes, special delicacy of the throat may render the 
child more sensitive to the diphtheritic poison, inclining him to take the 
disease where a stronger subject would escape altogether. Also the pres- 
ence of a catarrhal condition of the fauces at the time of exposure to the 
unhealthy influence increases the likelihood of infection. The scrofulous 
constitution has been said to induce a susceptibility to the diphtheritic 
virus ; and there is no doubt that the subjects of this diathesis are, as a 
rule, keenly sensitive to all forms of zymotic poison. 

Cold and moisture appear to have some influence in quickening the ac- 
tivity of the contagious principle, for the disease is common in country dis- 
tricts, especially in damp places, and is more prevalent during the winter 
months than at any other period of the year. 

"With regard io the exciting causes : There can be no question as to the 
highly poisonous nature of the exudation from the affected surfaces, for 
the discharges have often communicated the disease by coming into contact 
with a healthy mucous membrane. The virus may, however, be also con- 
veyed by more subtle emanations from the affected person ; and it is be- 
lieved that the contagious principle may be carried to a distance in the 
clothes of the patient himself after convalescence, or in the dress of a 
nurse who has not herself suffered from the disorder. Indeed, all the sur- 
roundings of the patient appear for some time to be capable of communi- 
cating the disease. It is even stated that in certain cases a convalescent 
may be still the channel through which the diphtheritic virus is conveyed to 
exceptionally susceptible subjects, although a period of months has elapsed 
since recovery from the disorder ; but in such a case it would be difficult to 
exclude other and more recent sources of infection. 

The poison may be drawn into the lungs with the air or swallowed in 
contaminated water ; but much uncertainty exists with regard to the laws 
which govern the transmission of the infective matter. Old cesspools and 
drains appear to preserve the contagium for a long time in a state of active 
virulence, but there is no proof that the poison can be generated spontane- 
ously from ordinary filth. The distemper may originate in a district 
under one set of conditions and be distributed under other and different 
conditions. There is no doubt that insanitary surroundings tend to favour 
the spread of the disease ; still it is probable that other influences also 
regulate the diffusion of the infection ; for when an outbreak occurs in any 
district, it is not always in the poorest and least cleanly localities — in parts, 
that is, where the disease would be expected to be most active— that the 
largest number of cases occurs. 

In many outbreaks certain faulty conditions, such as polluted water- 
supply, long standing accumulation of excrementitious matters, and imper- 



DIPHTHEKIA — CAUSATION — MOKBID ANATOMY. 91 

feet sewerage and drainage generally, are found to be common to all the 
dwellings in which the disease appears. These sanitary deficiencies are 
then held to furnish an explanation of the source of the infection. In other 
cases no such common conditions can be discovered, and the origin of the 
outbreak is less easy to account for. This was the case in an epidemic of 
diphtheria which occurred at King's Lynn, and was reported on by Dr. 
Airy. Here personal conveyance of the disease was positively excluded in 
the majority of cases. The milk was not at fault. The water-supply, the 
system of drainage, and the method of disposal of the excrement were in- 
sufficient, either singly or together, to explain the distribution of the infec- 
tion. It was, however, noticed that excavations had been in progress in 
the mud of the ancient river-bed and of a creek which had once been a sewer 
in connection with the town. Dr. Airy suggests that by this means " long- 
buried germs of some indigenous diphtheria, causing microzymes," may 
have been disengaged ; and that these carried amongst the inhabitants, 
and aided by season and atmosphere, may have given rise to the out- 
break. 

Dijmtheria is no doubt the consequence of a specific poison, however 
this may originate. The essence of the disease has been attributed to 
spherical bacteria (micrococci), which have been discovered swarming in the 
false membranes and exudations from the inflamed mucous surfaces ; but 
as similar bacteria have been found in the secretions thrown out by ordi- 
nary non-specific stomatitis, too much importance must not be attributed 
to the presence of these organisms. The real nature of the virus has yet 
to be discovered. The disease with which diphtheria has the closest affin- 
ity appears to be scarlatina. Epidemics of the two disorders are frequently 
seen to prevail in the same neighbourhood at the same time, and it was once 
supposed that the exciting causes of the two diseases were the same. It is 
now, however, acknowledged that they have no mutually protective power ; 
and there is no evidence that the contagion of diphtheria has ever given 
rise to scarlatina. 

Morbid Anatomy. — When the pharynx is examined the changes found 
on the inflamed mucous membrane are as follows : the surface becomes 
hypersemic and swollen, and after a few hours is covered with a whitish or 
yellowish layer which adheres closely to the mucous membrane beneath it, 
fitting accurately into every depression of the surface. The layer when 
first formed cannot be removed ; but as it increases in extent and thick- 
ness, it gradually becomes tougher, and can then be peeled off the surface 
to which it adheres. Later, it begins to loosen and may separate spon- 
taneously. When uncovered the mucous membrane may be found to be 
reddened and thickened, and if the inflammation has been severe, raw-look- 
ing or even ulcerated. 

On examination of the false membrane, it is found to present to the 
naked eye the appearance of coagulated fibrine ; but under the microscope 
is seen to consist of proliferated epithelial cells which are fused together into 
a network. These cells are cloudy from a peculiar degeneration of their 
protoplasm. A vertical section of the layer shows the undermost cells 
to be much smaller than those at the surface, and in a far less advanced 
stage of degeneration. Minute extravasations of blood are also scattered 
through the substance of the layer. If the vertical section be made in side 
and be carried down through the mucous membrane, it will be seen that 
the exuded layer is seated directly upon the basement membrane, taking 
the place df the ordinary epithelial coating. When the morbid process 
comes to an end, degeneration ceases ; a little purulent matter, formed by 



D2 DISEASE IN CHILDKEN. 

unaltered new cells mixed with serum, appears between the mucous surface 
and the false membrane covering it, and the latter is detached. 

In the larynx the mucous membrane is inflamed and swollen, and a 
fibrinous exudation is thrown out between the basement membrane and the 
epithelial covering. This on examination can be separated into layers con- 
sisting, according to Kindfleisch, of alternating strata of corpuscular ele- 
ments (leucocytes) and of fibrine. The superficial epithelial layer very 
quickly disappears. The micrococci, which are found in immense numbers 
in the false membrane, have been already referred to. According to Senator, 
these organisms are common to all forms of stomatitis, and are probably 
identical with the spores of the leptothrix buccalis. 

The consistence of the false membrane varies in different cases. It is 
often tough and tenacious, especially in the air-passages ; but sometimes is 
very soft and pultaceous. The latter condition is common when the false 
membrane occupies the pharynx in cases accompanied by severe constitu- 
tional symptoms and great bodily prostration. The more usual seats of 
the false membrane are the tonsils, uvula, soft palate and back of the 
pharynx ; the nasal passages ; the larynx and trachea. Less commonly it 
is found on the conjunctiva ; at the borders of the anus, and in girls of the 
vagina. Sometimes it appears on wounds of the skin. The mucous mem- 
brane is usually, as has been said, congested and swollen. It is very irritable 
and bleeds easily. Sometimes there is superficial ulceration, and in rare 
cases the ulceration extends deeply, and sloughing of the tissues may occur. 
Small ulcerations about the edges of the glottis are especially common in 
cases where the inflammation occupies the larynx. The cervical glands are 
swollen from rapid proliferation of small round cells, and the surrounding 
tissues are infiltrated with serum containing scattered pus-cells. 

Besides these local pathological changes, other organs of the body are 
often affected. Thus : — 

The lungs may be the seat of lobular pneumonia or collapse ; and the 
air-passages are sometimes lined with false membrane as far as their smaller 
branches. 

The heart, although itself showing no signs of disease, may have its 
right ventricle filled with a colourless ante-mortem clot which extends into 
the ventricle. It is sometimes stated that the lining membrane may be the 
seat of endocarditis ; but Parrot asserts that he has never met with endo- 
carditis in a case of fatal diphtheria. He believes that the beading else- 
where described, which is almost a natural condition in many young 
infants, has been mistaken for the result of inflammation. Pericarditis, 
however, is occasionally present ; and in a few instances a granular degen- 
eration of the heart-walls has been observed. This degeneration is con- 
sidered by Leyden, of Berlin, to be of an inflammatory character. It consists 
in a multiplication of the intermuscular nuclei which atrophy and form 
spots of degeneration. At the same time the muscular fibres undergo fatty 
degeneration. As a consequence of these changes the heart-walls become 
softer in consistence ; extravasations of blood take place into them ; and 
their cavities are dilated. 

The kidneys may be enlarged and pale, with more or less granular 
deposit in the renal cells. The cells themselves are often detached so as 
to block up the tubes. They are mixed with hyaline casts. 

Besides the above changes, there may be extravasation of blood into 
the various organs and beneath the mucous and serous surfaces. This 
occurs in the malignant form of other varieties of acute specific disease. 

On account of the frequent occurrence of paralysis during convalescence 



DIPHTHERIA — XOEBID ANATOMY — SYMPTOMS. 93 

from diphtheria., the nervous system hasheen carefully examined for signs of 
degeneration. Charcot and Tulpian were the first to discover indications 
or pathological change. In the year 1862 these observers detected granular 
degeneration of nerves and muscles of the soft palate. In the motor nerves 
of this part the tubules were emptied of their medullary substance, and 
their neurilemma contained many granular cells. Oertel, in 1871, found 
many extravasations in the substance of the brain, spinal cord, and spinal 
nerves in a case where death had occurred from diphtheritic paralysis with 
general atrophy of muscle. Similar extravasations have been found by 
I bL In addition, this observer noticed the nerves to be thickened at 
their roots, and their sheaths to be filled with hypertrophic d lymphoid 
cells and nuclei. Dejerine, in five cases of death in children from diph- 
:.. ."tic paralysis, found in each instance changes strictly limited to the 
nerves supplying the paralysed parts. These changes consisted in a degen- 
f. :::>n of the anterior roots similar to that which takes place in the distal 
end of a nerve after section. He attributes the degeneration to changes 

O fcj 

in the gray matter of the anterior cornua. 

There is no doubt that diphtheria is a specific contagious disease, and 
that it is, at least finally, a constitutional one ; but opinions differ as to 
whether the malady is constitutional from the first. The more commonly 
received opinion is, perhaps, that the affection is always a constitutional 
one, and that the throat lesion is its chief local expression, analogous to 
the rash of specific fevers. Some pathologists are, however, inclined to 
believe that the lesion of the mucous membrane is at first a purely local 
ailment resulting directly from contact with the poison, just as the pustule 
of small-pox may be excited locally by the process of inoculation. Accord- 
ing to this view the constitutional suffering would be of the nature of sep- 
ticaemia, the blood being directly contaminated by absorption of a specific 
virus from the diseased spot. The well-known influence of a catarrhal 
state of the fauces in increasing the susceptibility of the individual to the 
diptheritic contagion seems to lend support to this theory. 

Symptoms. — As in all forms of zymotic disease, the onset of the illness 
is preceded by a period of incubation. This period may occupy only a 
few hours or may List for a week or eight days before the symptoms of in- 
vasion are noticed. 

Cases of diphtheria may be divided, according to the gravity of the 
symptoms, into the mild, the severe, and the malignant forms. 

In the mild form of the disease the child is a little feverish, often com- 
plains of headache, and is unwilling to swallow solid food. The fever is 
slight, the temperature often rising to between 10 l c and 10 '2°, seldom 
higher. (Thus, in the case of a little girl, aged two years and ten months, 
temperature: second day, morning, 99.4' ; evening, 10L6°. Third day, 
morning, 99.4" ; evening, 101". After this date the temperature was normal 
both morning and evening. ) In all cases there is some languor and loss 
of spirits with a certain expression of distress in the face. Even in slight 
eases a little change is noticed in the quality of the voice, which becomes 
nasal or throaty. Vomiting is not common in the mild form, although in 
the severer cases it may be a frequent and distressing symptom. Some- 
times the symptoms are even less marked. The child may take his food 
as usual without any complaint, and only show his indisposition by a cer- 

- pallor of face and want of sprightliness in his k 

When the throat is examined, the fauces are found to be red and 
swollen, but more on one side than on the other ; the uvula is distinctly 
increased in size ; and on one or both tonsils a gray or fawn-colored. 



94 DISEASE IN CHILDBED. 

tough-looking opaque patch will be seen, usually occupying the anterior 
face. The patch may be a continuous layer of some consistence, or may 
be composed of spots of false membrane scattered over the surface. These, 
however, soon unite so as to form a more coherent coating. In all cases 
the glands at the angles of the jaw are tender and enlarged ; but this 
symptom is often not marked until the end of the second or the beginning 
of the third day. 

In the mild form the temperature often falls after three or four days. 
The general symptoms continue trifling ; the child takes food with appe- 
tite ; and unless he attempt to swallow solid food, deglutition is accom- 
panied by little distress. The false membrane may spread a little along 
the soft palate, but usually remains limited in extent. Very quickly it be- 
gins to separate at the edges and then becomes detached. In rare cases, 
after spontaneous separation of the first patch of membrane a second ap- 
pears upon the mucous surface. I have known this to happen in one in- 
stance. The sore throat may be accompanied by some discharge from the 
nose. Usually, at the end of a week or ten days the child is convalescent 
from the throat affection ; but it still remains to be seen whether he will 
escape after ill-consequences. 

In the severe form the disease may be severe from its intensity or dan- 
gerous from its seat. Thus, it may spread widely over the pharynx and be 
accompanied by signs of serious constitutional suffering ; or may attack 
the larynx and, although limited in extent, produce the gravest conse- 
quences from interference with the respiratory process (membranous 
croup). 

Severe pharyngeal diphtheria may begin with the mild general symp- 
toms which are common in the slighter form which has been described ; 
or may be accompanied by much more serious phenomena. Thus, the 
child complains of difficulty of swallowing and of racking headache ; his 
face is pale and distressed ; fever is high ; vomiting may occur on any at- 
tempt to take food ; and the patient may even be convulsed. The false 
membrane in the throat is thick and generally coherent. It spreads rapidly 
over the tonsils, the soft palate, and the back of the pharynx ; often pene- 
trates into the nasal fossae, or forms patches on the cheeks, the gums, and 
the lips. The odor of the breath is soon noticed to be fetid or even gan- 
grenous ; and a thin offensive discharge escapes from the nostrils and 
forms crusts at the openings of the nares. 

The submaxillary glands are enlarged and tender ; and there is much 
swelling of the neck. Sometimes haemorrhages occur from the nose, 
throat, and gums. The face is pale with a tendency to lividity ; the pulse 
is rapid and feeble ; appetite is completely lost ; the bowels are generally 
relaxed with thin offensive stools ; and there is great prostration. Some- 
times in these cases the false membrane is loose in consistence and may 
even be pultaceous. It may assume a dirty gray or brownish hue, and is 
sometimes almost black from admixture with blood. 

When the end is favourable this form lasts for ten days or a fortnight. 
After a time, if no serious complication occurs, the false membrane sepa- 
rates and is not renewed ; the swelling subsides ; the pulse becomes 
stronger ; the appetite begins to return ; and the child enters into con- 
valescence, although for some time he remains anaemic and feeble. Often, 
however, the patient dies at the end of the week either from exhaustion, 
from extension of the inflammation to the larynx, or from one of the com- 
plications to be afterwards described. The mind is usually clear through- 
out, although in the worst cases— those in which the disease approaches 



DIPHTHERIA— SYMPTOMS. 95 

most nearly to the malignant type — death may be preceded by delirious 
wanderings or stupor. In such cases a real septicaemia may occur, the 
blood being poisoned by the absorption of foul putrescent matters in con- 
tact with the tissues of the pharynx. The child often shivers, and his 
temperature rises to 103 °or 104°, often sinking again in rapid daily varia- 
tions. The pulse is small and feeble ; the eyes sunken and dull-looking ; 
the complexion of a dirty yellow tint. There is often epistaxis ; the cer- 
vical glands swell to a large size ; and the loose areolar tissue of the neck 
is infiltrated with serum. The prostration is extreme ; apathy is complete ; 
delirium comes on ; and the child quickly dies. 

In severe diphtheria the amount of fever varies. Even in very bad 
cases it need not be high. Sometimes the temperature is 103° or 104° at 
the beginning of the illness, and sinks to the normal level or even below 
it when the more serious symptoms declare themselves. Sometimes after 
falling it may again become elevated and reach 106° or higher before 
death. Some inflammatory complication is then probably present. 

Albuminuria is a frequent symptom. It occurs in about two-thirds of 
the cases, but does not necessarily imply gravity in the prognosis. Its 
amount is usually in proportion to the extent of surface involved. The 
albuminuria appears to be the consequence of a rapid elimination through 
the kidneys of poison absorbed from the affected mucous membrane. In 
severe cases it may be found as early as twenty-hours from the beginning 
of the illness. This is, however, exceptional. Usually it appears on the 
third or fourth day, but it may be sometimes delayed as late as the ninth 
or tenth. Sometimes the urine is smoky. It contains an excess of urea, 
and hyaline and granular casts may be detected in the deposit. The kid- 
neys are in a state of mild parenchymatous nephritis, but this passes off as 
convalescence becomes established, and rarely leaves ill consequences be- 
hind. It is very rare for unemic symptoms or dropsy to occur. 

When the disease attacks the larynx (laryngeal diphtheria ; membranous 
croup) the child is at once in serious danger. In the majority of cases the 
laryngeal disease is due to extension of inflammation from the fauces. 
Less commonly the inflammation begins in the trachea and spreads thence 
upwards and downwards. Cases where the disease develops originally in 
the glottis (the so-called true membranous croup) are very rare. Still 
rarer are the cases where the false membrane remains limited to the glot- 
tis. In my own experience I cannot call to mind a single case of mem- 
branous laryngitis in which some evidence of false membrane in other 
parts was not to be obtained. In most cases there was also exudation in 
the fauces. In a few the membrane had spread down the trachea and the 
fauces were free ; but even in these cases patches of exudation were usu- 
ally found on examination after death at the back of the nares. 

The extension to the air-passages often takes place quite suddenly and 
unexpectedly. The preceding symptoms had been slight, attracting little 
attention, when suddenly the breathing is noticed to be stridulous. The 
symptoms of membranous croup then develope themselves with startling 
rapidity. Usually the sore throat and signs of catarrh continue for sev- 
eral days before any more alarming symptoms are observed. The child is 
not thought to be ill. He seldom refuses his food ; and although a 
little languid and unusually anxious for drink, does not appear to be dis- 
tressed. 

When the laryngeal disease begins the breath-sounds lose their ordinary 
character and become harsh and stridulous. At the same time the cough is 
hard and harsh and the voice and cry are hoarse. The change in the char- 



06 DISEASE IN CHILDREN. 

acter of the breathing may be the earliest of the new symptoms, or may 
be preceded by the change in the voice and cough. 

This stage of the disease may continue for several days ; but often after 
a few hours the breathing becomes greatly oppressed, and attacks of violent 
dyspnoea throw the patient into the greatest distress. In these attacks, 
however violent they may be, there is no orthopnoea, for the breathing is 
not more oppressed when the head is low. As a rule, the child lies back 
in his cot or in his mother's arms. His face is livid ; his mouth is open ; 
his eyes stare wildly, and he looks dreadfully anxious and frightened. The 
dyspnoea affects both respiratory movements. Each inspiration is pro- 
longed, high-pitched, and metallic ; the expirations shorter and harsh ; the 
cough hoarse and whispering. If the chest is uncovered at this time it 
will be noticed that at each inspiration the lower half of the breast-bone 
bends inwards so as to leave a deep pit in the epigastrium. At the same 
time the intercostal spaces deepen and the supra-sternal notch is depressed. 
The attack of dyspnoea lasts from a few minutes to a quarter of an hour or 
longer. When it subsides the child's terror disappears ; his breathing be- 
comes less noisy and stridulous ; his respiratory movements less laborious, 
and he passes into a state of comparative ease. Still, the breathing is 
rapid and audible ; the nares work violently ; some lividity remains in the 
face, and there is considerable recession of the soft parts of the chest in 
inspiration. On examination of the chest, the breath-sounds are accom- 
panied by a stridor conducted from the larynx, and this may completely 
conceal all natural vesicular murnxur. 

The attacks of dyspnoea return at short intervals, and are easily excited 
by movement or by anything which irritates or agitates the patient. The 
cough occurs frequently and is hoarse and whispering. Sometimes the 
patient expectorates patches or shreds of false membrane ; but unless the 
trachea be opened the child rarely expels enough of the obstructing sub- 
stance to produce appreciable relief to his symptoms. At each recurrence 
of the dyspnoea the attack is more severe than before, so that gradually the 
child passes into a semi-asphyxiated state. He lies back with purple lips 
and livid face ; his pulse is feeble, frequent, and very irregular ; his breath- 
ing rapid and shallow, although his nares still work ; his forehead clammy, 
and his extremities cold. He often moves his arms restlessly, and his 
heart's action may become very intermittent, a curious pause taking place 
between every two or three pulsations. On examination of the chest there 
is usually good resonance, except perhaps at the extreme base. The breath- 
sounds are obscured by conducted stridor and may be accompanied by dry 
rhonchus. If no operative procedure be attempted the drowsiness deepens 
into stupor, and the child sinks quietly or dies in a last struggle for 
breath. 

If a-t this stage the trachea be opened, the immediate effect of the 
operation is most striking. In a favourable case, where the trachea below 
the opening is not obstructed, the child is at once relieved from almost all 
his distress. Air again penetrates deeply into the lungs ; the lividity dis- 
appears ; the restlessness subsides ; the breathing becomes natural ; the 
nares cease to act, and the look of terror and suffering passes off and may 
even be succeeded by a smile. 

When the disease thus attacks the larynx the duration is usually very 
short. From the time when the first signs of stridulous breathing are 
noticed to the end only a few hours may elapse. In other cases the child 
may live two or three days ; but this longer duration is due to slower 
progress in the earlier part of the illness. When serious dyspnoea super- 



DIPHTHERIA— COMPLICATIONS. 97 

venes the child, if not relieved by operation, seldom survives the next 
twenty-four hours. Sometimes, however, if the false membrane is very 
limited in extent, recovery may take place. In these cases the symptoms 
are seldom very severe, and in particular the attacks of dyspnoea, if pres- 
ent at all, are mild and infrequent. The favourable change is marked by a 
less laboured character of breathing, a brighter look in the face, increased 
looseness and more natural quality of the cough, and a return of tran- 
quillity to the manner. Still, there is little doubt that many cases of 
supposed recovery from membranous croup are really cases of stridulous 
laryngitis, which is a much milder complaint and rarely ends fatally. 

In the malignant form of the disease the constitutional symptoms are 
very severe, and may be quite out of proportion to the amount of local 
lesion. Vomiting is usually frequent. There is often diarrhoea. The 
child is pale and haggard-looking, and seems stupid and drowsy. His skin 
is spotted with petechia. His pulse is rapid, small, and feeble. His feet 
and hands are cool and clammy, and even the internal temperature of the 
body seldom reaches a high elevation. Sometimes, indeed, it is normal or 
even subnormal. Thus a little boy, aged two years and a half, was ad- 
mitted into the East London Children's Hospital with wash-leather-like 
exudation on the fauces, great swelling of the cervical glands, and marked 
prostration. In this boy the temperature never rose above 98.2°, and a few 
hours before death was only 97° in the rectum. The child died two days 
after admission in a convulsive fit. 

The false membrane is generally of a dirty-brown colour. Extension of 
the inflammation takes place rapidly into the nose ; epistaxis often occurs, 
or there is a flow of thin blood-stained fluid from the nostrils. Sometimes 
the lachrymal ducts become obstructed ; the eyes then look watery, and 
false membrane may even appear on the conjunctivae. The mucous mem- 
brane of the fauces may become ulcerated or gangrenous, and the smell 
from the mouth is very offensive. Haemorrhages may occur from the gums 
and throat. The urine is often smoky and almost always albuminous. 
Delirium comes on followed by stupor, and the child dies exhausted. 

Secondary Diphtheria. — Sometimes diphtheria occurs secondarily to some 
acute disease. Thus it may arise as a complication of typhoid fever, 
pyaemia, erysipelas, measles, scarlatina, whooping-cough, or other form of 
acute illness. In these cases the amount of false membrane is usually 
limited in extent, but the inflammatory process is apt to run on into ul- 
ceration or even gangrene. The ulcers are rounded or sinuous, and may 
penetrate deeply into the tissues. Gangrene is not common. It usually 
occurs in the tonsils and pillars of the fauces. These parts become gray 
and exhale a most offensive odour. The sloughs separate after a time and 
leave grayish, unhealthy-looking pits which in favourable cases may heal, 
with considerable contraction of tissue in the affected parte. 

Complications. — The ordinary course of diphtheria may be interfered 
with by various complications which delay recovery or unfavourably in- 
fluence the issue of the illness. The occurrence of albuminuria cannot 
be looked upon as a complication. This symptom is found in mild as 
well as in severe cases, and is far more often present than absent. It ap- 
pears to be the consequence of elimination of the poison by the kidneys, 
and has probably little influence on the prognosis. The complications 
which will be considered consist of the formation of false membrane in 
unusual situations ; the occurrence of inflammation of special organs, such 
as the lungs, the heart, and the pericardium ; the formation of a thrombus 
in the heart or large vessels ; and the appearance of paralysis. 
7 



98 DISEASE IN CHILDEEN. 

Nasal diphtheria has been already referred to as constituting a symp- 
tom of the malignant type of the disease. A diphtheritic coryza is, how- 
ever, sometimes seen as a complication of milder attacks. In these cases 
a thin discharge flows from the nostril, usually at first on one side only. 
It produces some excoriation of the margin of the nasal opening as well as 
of the upper lip, for these parts are often red and raw -looking. No doubt 
the presence of false membrane in the nasal passages is a sign of the ut- 
most gravity ; but I have known coryza with excoriation of the nostril to 
occur in cases of a comparatively mild nature without producing an unfa- 
vourable influence upon the course of the illness. 

Sometimes in epidemics of diphtheria more unusual manifestations of 
the disease are met with. The false membrane may form upon the con- 
junctivae, the external auditory meatus, the outlets of the vagina and rec- 
tum, upon the glans penis, and upon any wounds or abraided surfaces 
present on the skin. Often after tracheotomy the edges of the wound 
quickly become covered by the diphtheritic exudation. These exceptional 
seats of the false membrane may be the only local signs of the disease 
to be discovered, or may be accompanied by the usual affection of 
the throat. When a wound or abraided surface becomes attacked by the 
diphtheritic process, its borders become purple-red and swollen, and the 
surface pours out a profuse, watery, fetid discharge. Soon a pellicle 
forms on the sore, and from this point the disease may spread over the 
skin. Thus the discharge irritates the neighbouring cutaneous surface ; 
little vesicles form, break, and become themselves converted into diphthe- 
ritic sores covered by the characteristic false membrane. In this way, ac- 
cording to Trousseau, the diphtheritic process may spread over a large ex- 
tent of surface ; and the layers of membrane, constantly moistened by the 
discharge, undergo rapid decomposition, and give out a most offensive 
gangrenous stench. The general symptoms in such cases are very severe, 
and the patient usually sinks rapidly from exhaustion. 

Inflammatory complications sometimes arise in the course of diphthe- 
ria. After the operation of tracheotomy for membranous croup, it is un- 
fortunately far from uncommon to find the temperature rise to 102° or 
103°, and to discover, on examination of the chest, all the signs of acute 
consolidation of the lung. Sometimes, however, the pulmonary lesion is 
an early complication. In any case it greatly lessens the child's chances 
of recovery. 

Inflammation of the pericardium and endocardium are occasional com- 
plications of the illness. Pericarditis occurring alone will probably be 
overlooked without a careful examination of the precordial region. Endo- 
carditis also may give rise to but few symptoms, and is often only dis- 
covered on examination of the body after death. "We must, however, be 
on our guard, and avoid attributing to endocarditis the hsematomatous 
beading of the mitral valve described by Parrot. (See page 546.) 

When a thrombus forms in the heart, death may occur either suddenly 
at the moment of formation of the coagulum, or gradually after an interval 
of much anxiety and suffering. Usually the symptoms appear quite sud- 
denly, and at a time when the child seems to be going on favourably to con- 
valescence, or even after recovery is far advanced. If the formation of the 
clot does not bring the case to a sudden termination, marked dyspnoea is 
one of the earliest signs of the accident. 

Dyspnoea arising from want of blood in the pulmonary circulation is 
shown, as Dr. Eichardson has pointed out, by symptoms very different in 
character from those due to an obstructed larynx. In the first case, al- 



BIPHTHEEIA — PAKALTSIS. 99 

though the breathing is laboured, the lungs are full of air and may even 
be distended with it sufficiently to produce in the younger subjects a pecu- 
liar prominence in the anterior part of the chest. There are no signs of 
imperfect aeration of blood, but all the symptoms indicate obstruction to the 
circulatory current. Thus the lips and cheeks are blue ; the jugular veins 
distended ; the heart-impulse quick, feeble, and irregular. The body is 
cold and pale ; it may be marbled, especially at the extremities ; and there 
is intense anxiety and constant movement. When death occurs, the heart 
ceases to act before the respiratory movements have come to an end. 

On the other hand, when apncea occurs from laryngeal obstruction the 
symptoms all point to imperfect aeration of blood. The surface of the body 
is dusky instead of pale ; the heart-sounds are clear ; the cardiac impulse 
is feeble but rarely tumultuous ; the lungs are congested but not emphyse- 
matous ; there is great recession of the epigastrium and soft parts of the 
chest at each inspiration ; the muscles are convulsed ; and the breathing 
stops before the movements of the heart cease. 

Sudden death is due in most cases, probably, to the rapid formation of 
a clot in the right side of the heart. It may be also the consequence 
of paralysis of the cardiac branches of the par vagum ; but in cases where 
the sudden end has been attributed to this cause, a granular degeneration 
of the cardiac muscular fibres with softening of the walls and dilatation of 
the cavities has been discovered on careful examination. Leyden suggests 
that the cardiac failure is the result of these changes. According to this 
observer, dangerous weakness of the heart from this cause is indicated by 
gallop-rhythm of the heart-sounds with weakness of the impulse and irreg- 
ular tremulous contractions. Vomiting, due to a reflection of the disturb- 
ance to other parts of the pneumogastric nerve, indicates that the danger is 
pressing. Other observers have noted precordial distress, extreme dysp- 
noea, smallness and irregularity of the pulse, and attacks of palpitation 
alternating with slowness of the pulsations. H. Weber has found the pulse 
fall to twenty-eight or even sixteen beats in the minute. 

In a certain proportion of cases of diphtheria convalescence is inter- 
rupted by the appearance of paralytic lesions. The frequency with which 
this complication is found to occur has been variously estimated. Probably 
it depends in some measure upon the character of the epidemic. The de- 
gree, too, to which the nervous system is affected is subject to great 
variety. In some cases the lesion is so trifling as scarcely to attract atten- 
tion. In others it amounts to well-defined and general loss of power. 
Taking mild and severe forms together, the proportion of patients who 
suffer from the complication is probably one in every ten or twelve cases. 

Diphtheritic paralysis is not limited to cases in which the throat affec- 
tion has been severe. The slighter forms of the distemper are as liable as 
the more serious forms to be followed by the nerve-lesion. Nor is its oc- 
currence determined by the seat of the diphtheritic manifestation or the 
presence or absence of albuminuria. It may follow in cases where the false 
membrane has been limited to the skin, and in cases where albuminuria 
has not been observed. The period at which the paralysis appears is also 
subject to variety. From an analysis of sixteen cases Dr. Abercroinbie 
found that the paralytic complication might appear from two to five weeks 
from the beginning of the illness. Sanne has noticed it as early as the 
second or third day of the disease, but states that it generally comes on 
from one to two weeks after the disappearance of the false membrane. 
According to this observer, when the paralytic symptoms appear early they 
usually develop gradually and spread slowly from one part to another. 



100 DISEASE IN CHILDREN. 






When the onset is retarded, the development of the paralytic phenomena 
is much more rapid and regular. 

The motor lesion may be preceded by increase of languor and irritabil- 
ity of temper. Dr. Hermann Weber has noticed in many cases a marked 
diminution in the rapidity of the pulse. The paralysis is symmetrical as a 
rule. Usually it begins either by loss of power in the soft palate and phar- 
ynx or, by what is equally common, paralysis of accommodation of the 
eye. It is noticed that when the child attempts to swallow he coughs vio- 
lently and fluids return through the nose. His voice has a nasal quality 
and he snores in his sleep. If the patient is old enough we can ascertain 
by inspection that he has no power of elevating the uvula, and perhaps, 
also, that there is more or less anaesthesia of the fauces. If the ocular 
muscles are affected the child complains that he sees double. Reading is 
difficult or impossible, and sometimes there is an evident squint. In rare 
cases there is temporary blindness. 

When the pharynx is first affected the paralysis may remain limited to 
this part. If it be complete, the power of swallowing is lost and food can 
no longer be propelled down the gullet. The food taken is found to col- 
lect in a pouch formed by yielding of the walls of the oesophagus. In such 
cases nourishment has to be conveyed to the stomach by mechanical means. 
The use of the stomach-tube is of the greatest service in these cases, both 
as a method of maintaining nutrition and also as a means of preventing 
the entrance of food into the glottis. From the pharynx the paralysis may 
spread to other parts. The tongue and lips may become affected so that 
the child dribbles and speech is greatly interfered with. Loss of power 
may also be noticed in the limbs, the neck, and the back. Of the limbs, 
the legs are affected more commonly than the arms. The paralysis almost 
invariably takes the form of paraplegia, for even if the weakness is more 
marked on one side, it will be usually found on examination that the side 
which appears to be sound has not entirely escaped. The motor paralysis 
may be accompanied by some disturbance of sensation. In rare cases con- 
trol over the sphincters is lost. Paralysis of the respiratory muscles some- 
times occurs. There is then dyspnoea : mucus collects in the lungs, for 
there is no power to cough it up ; and the child usually dies suffocated. 
If the diaphragm is paralysed the child has attacks of dyspnoea, coming on 
at the slightest excitement or when an attempt is made to cough. Death 
may ensue in such an attack. The most moderate catarrh in such a con- 
dition adds an additional element of danger to the case. 

Besides these forms of motor lesion, sudden death, attributed to paraly- 
sis of the heart, has been already referred to (see page 99). 

Diphtheritic paralysis is fatal only in exceptional cases. When death 
occurs, it is usually the consequence of cardiac thrombosis or syncope ; 
less commonly it is due to impaired nutrition through difficulty of swal- 
lowing, or to nervous exhaustion. Eecovery is the rule, and the rapidity 
with which this takes place is very variable. The course is much snorter 
in cases where the paralysis is limited to the palate. This usually passes 
off in a fortnight or three weeks. When the loss of power becomes gen- 
eral, a cure is effected with much greater difficulty ; but even in these cases 
it seldom lasts longer than three, or at the most four months. Sometimes 
the limbs recover their power very rapidly while the pharynx remains ob- 
stinately paralyzed for a considerable longer period. 

Diagnosis. — When diphtheria gives rise to well-marked symptoms, its 
detection is easy. The tough-looking gray or fawn-coloured membrane in 
the throat, the redness and swelling of the fauces, and the enlarged cei> 



DIPHTHEEIA — DIAGNOSIS. 101 

vical glands are sufficiently characteristic. In tonsillitis the uvula is not 
swollen, and the whitish exudation occupying the mouths of the crypts, 
and sometimes spotting the surface of the tonsils, is very different in ap- 
pearance from the consistent false membrane of diphtheria. It never forms 
a coherent layer, and never invades the nares or the larynx. Moreover, 
in quinsy, although the swollen tonsils can be felt externally, the cervical 
glands are seldom appreciably enlarged. If, in diphtheria, the exudation 
is soft and pultaceous, instead of being coherent and tough, there is still 
enlargement of the superficial cervical glands, and the general symptoms 
indicate profound depression. Any huskiness or weakness of the voice 
implies extension of the inflammation to the larynx, and points unmistak- 
ably to diphtheria. The difficult cases to detect are those in which the 
throat affection is imperfectly developed, or is slow to appear. At first, 
nothing may be noticed but redness and swelling of the fauces, with some 
discomfort in swallowing. In such cases until the false membrane ap- 
pears, we cannot say that we have not to deal with an ordinary inflamma- 
tory sore throat ; for although the weakness and pallor of the patient are 
usually out of proportion to the apparent mildness of the local affection, 
no positive inference can be drawn from this discrepancy, as some chil- 
dren are more depressed than others by a trifling ailment. If such a con- 
dition be met with at a time when diphtheria is known to be prevalent, 
we should regard the symptoms with much apprehension. Indeed, in any 
case of sore throat, if enlargement of the glands of the neck can be dis- 
covered, we should withhold a positive assurance that the complaint is one 
of little consequence. Sometimes the appearance of albumen in the urine 
comes opportunely to clear up a doubtful case. Sometimes after the ter- 
mination of an ill-defined angina, the occurrence of paralysis throws a new 
light upon the past indisposition. 

Laryngeal diphtheria, or membranous croup, may be confounded with 
stridulous laryngitis, with abscess of or about the larynx, or with retro- 
pharyngeal suppuration. The distinctive points between these diseases 
will be referred to in the chapters treating of these affections. It is pos- 
sible that a foreign body in the air-passages may be mistaken for croup ; 
but the attack of dyspnoea produced by this means comes on quite sud- 
denly and follows at once upon an attempt to swallow. There is spas- 
modic cough but no hoarseness ; and the first paroxysm of suffocation and 
cough is usually succeeded by a period of quiet in which, for the time, the 
breathing is fairly easy and the child seems to be well. 

It is very important to be able to discriminate between cases in which 
tracheotomy may be expected to succeed and those in which no perma- 
nent good can be anticipated from the operation. Dr. George Buchanan, 
of Glasgow, has pointed out that in cases where the air-passages below the 
point of obstruction are free, and the lungs are in a normal condition, 
there is great recession of all the soft parts of the chest. At each inspira- 
tion the intercostal spaces fall deeply in, and the epigastrium forms a deep 
hollow. If, on the contrary, the smaller bronchial tubes are full of mucus 
or diphtheritic exudation, the movements of the chest- wall are impeded, 
and the chest is puffed out so as to resemble the distended thorax of 
chronic emphysema. 

If the patient be seen for the first time when the paralytic symptoms 
have declared themselves, the history of the attack will declare the nature 
of the disease. Even if, as sometimes happens, the throat affection has 
been too slight to constitute a regular illness, we shall find, probably, that 
other members of the household have suffered from diphtheria, and that, 



102 DISEASE IN CHILDREN. 

in the child himself, any signs of general nerve-lesion have been preceded 
by a nasal tone of voice, some trouble in swallowing, and the occasional 
return of fluids through the nose. 

According to M. Landrouzy, if a child who is convalescent from diph- 
theria begins to suffer from attacks of dyspnoea excited by an attempt to 
cough, or by any small vexation, we should suspect paralysis of the dia- 
phragm in the absence of any more evident explanation of the distressing- 
phenomenon. 

Progiiosis. — Even in the mildest attack of diphtheria we must be 
guarded in the expression of our opinion as to the probable issue of the 
illness. Indeed, it is wiser to express no opinion upon the matter, but 
to confine ourselves to reporting the daily progress of the case, and speak- 
ing cheerfully so long as no symptoms arise indicative of danger. We can 
never feel certain that the inflammation may not spread to the larynx, or 
that other ill consequences may not ensue, however favourably the disease 
may appear to be going on. Caution in prognosis is especially necessary 
if the epidemic is a severe one, for outbreaks of the distemper vary 
greatly in the severity of type of the illness, and in some the mortality is 
much greater than it is in others. The age of the patient is also an impor- 
tant item to take into consideration, for a young child has fewer chances 
of recovery than an older one. 

Different dangers are to be apprehended at different periods of the dis- 
ease. During the first week we dread lest the inflammation should 
spread to the larynx, or lest the child should die from septicaemia. We 
therefore notice carefully the character of the breathing and the quality of 
the voice. If the breathing become shrill and the movements laboured, or 
the voice get weak or husky, we can have no doubt that the larynx is be- 
coming involved. So, also, in cases where the false membrane is thick, 
pulpy, and putrescent the occurrence of shivering or a sudden rise in the 
temperature, with a dull yellow tint of the face and a rapid feeble pulse, 
makes us fear that the blood is becoming poisoned by absorption from the 
affected mucous membrane. Dr. Jacoby has pointed out that in nasal 
diphtheria septicaemia is especially liable to occur. In this form of the 
disease, therefore, the regular use of disinfecting injections is imperatively 
called for. 

After the first six or seven days the child is in danger of death from 
syncope, from clotting of blood in the heart, and from inflammatory com- 
plications. At this time we carefully watch the pulse. If this fall notably 
in frequency and strength, especially if at the same time vomiting occur 
and be often repeated, the danger is imminent. At this period of the dis- 
ease haemorrhages sometimes come on as a result of profound blood con- 
tamination and are very exhausting. Other signs of bad augury are : a 
very feeble frequent pulse, cardiac dyspnoea (see page 98), general swell- 
ing of the neck, great prostration, and delirious wanderings. Albumi- 
nuria, unless excessive, is not necessarily a grave symptom. 

When the diphtheritic exudation invades the trachea the danger is very 
serious ; but if the operation of tracheotomy be performed in time, and a 
marked retraction of the chest-wall indicates that the smaller tubes are 
free below the point of obstruction, and that air, if admitted, will be able to 
penetrate to the alveoli, recovery is far from impossible. After the oper- 
ation, success depends chiefly upon the child's capability of taking and di- 
gesting his food, and upon the lungs remaining free from pneumonia. If 
there is difficulty in administering nourishment, the child can be still fed 
through the stomach-tube ; but loss of appetite usually implies feeble di- 



DIPHTHEEIA— PEOGNOSIS — TEEATMENT. 103 

gestive power, and the prospect is not favourable. If pneumonia occur, the 
prognosis is gloomy. 

After the end of the second or third week nervous symptoms may be 
expected. In these the prognosis is favourable. It only becomes serious 
when the lesion is widely diffused, when all the muscles of deglutition are 
affected so that swallowing becomes impossible, or when the diaphragm 
and respiratory muscles are attacked. No child, however, should be al- 
lowed to die of starvation, for nourishment can always be administered at 
regular intervals through the stomach-tube passed through the nose. 

Treatment — Diphtheria is an infectious disease, and the ordinary pre- 
cautions must therefore be taken against its spread. The sick room should 
be divested of carpets, rugs, curtains, and superfluous furniture ; and 
proper measures should be taken to disinfect all discharges from the patient 
before removal. 

The child must be kept quiet in bed. It is well to place him in a tent 
bedstead and to envelop him in an atmosphere of steam impregnated with 
thymol, creasote, or other disinfectant. This may be most conveniently done 
by the use of the " croup kettle " designed by Mr. E. W. Parker, on the 
principle of Dr. Lee's "steam draught inhaler." Creasote or carbolic acid 
may be added to the water in the kettle in the proportion of twenty drops 
to the pint, or a saturated solution of thymol can be made use of. So 
manjr technical matters have to be attended to in the treatment of these 
cases that whatever be the age of the child the assistance of a skilled nurse 
is indispensable. Amateur nursing, seldom if ever satisfactory, is here a 
serious disadvantage to the patient, and introduces into the case an addi- 
tional element of danger. 

The treatment of the disease comprises general and local measures, and 
these are of about equal importance. 

The general treatment consists in employing every means to support 
the strength of the child, so as to enable him to struggle successfully 
against the exhausting influence of the disorder. The patient should be 
supplied with food of a nourishing and digestible kind. Strong beef es- 
sence, yolk of egg, milk thickened with Chapman's entire wheat flour 
baked in an oven, pounded underdone meat made fluid with strong meat 
juice or meat essence, all these are very useful. Alcohol must not be for- 
gotten, and will often have to be given in full doses. Old brandy or 
whiskey, with or without yolk of egg, should be given at the first sign of 
feebleness of the pulse. A child five years of age will take with benefit 
thirty drops of good brandy every two hours. In infants white wine whey 
given freely is very useful. In giving stimulants we must be guided by 
the state of the pulse, or in infants by the condition of the fontanelle. As 
long as the pulse is firm or the fontanelle little depressed, alcohol is not re- 
quired, when the pulse gets soft and compressible, or the fontanelle sinks, 
stimulants must be given without delay. It some cases they will be re- 
quired from the first. 

In the selection of medicines preference should be given to such as do 
not cause depression. In diphtheria there is a tendency to failure of the 
heart's action ; and this tendency is likely to be favoured by the use of de- 
pressing remedies, such as the salicylate of soda, which has been sometimes 
recommended. A simple febrifuge may be given while the temperature is 
high and the skin dry ; but directly the strength shows signs of failing, iron 
and quinine should be resorted to. The perchloride is perhaps as good a 
preparation as any other. Ten or fifteen drops of the tincture may be 
given with one grain of quinine every three hours to a child five years of 



104 DISEASE IN CHILDEEN. 

age. Much larger doses of the drug are often recommended ; but young 
children vary greatly in their capacity for benefiting by chalybeate remedies, 
and in weakly subjects the stomach may be readily deranged by an excess 
of the medicine. Now it is of the first importance to maintain the digestive 
power, as incomparably the best tonic for a child is nourishing food. 

Instead of quinine, chlorate of potash is often conjoined with the iron ; 
but this remedy should be given with caution as it has a depressing effect 
on some children. It is well to begin the treatment with a mercurial 
purge, such as gray powder with jalapine, but the aperient need not be 
afterwards repeated. 

In the use of local remedies we have to fulfil three indications : to arrest 
the spread of the false membrane ; to promote its removal, and to prevent 
septicaemia from absorption of putrescent matters in contact with the tissues. 

Many measures have been employed to prevent the extension of the 
local lesion in the throat. At one time strong cauterising agents were 
resorted to to effect this purpose, such as the solid nitrate of silver, equal 
parts of strong hydrochloric acid and honey, and the strong solution of 
per chloride of iron. The repeated use of these agents is now almost 
universally condemned, but one thorough swabbing of the throat is still 
advocated by some writers. I have occasionally employed equal parts of 
strong perchloride of iron solution and glycerine, and have thought that 
used efficiently, once for all, the application has been followed by benefit. 
Many writers, however, deprecate the use of these powerful agents ; and 
certainly, since I have abandoned their employment, I have not found the 
disease less tractable or more dangerous to life. 

To promote the liquefaction or removal of the false membrane many 
agents are employed. Rough tearing away of the diphtheritic exudation 
is injurious as well as useless ; but gentle measures to further its destruc- 
tion are decidedly beneficial. To be of service, however, the application 
must be used repeatedly, and can be applied with perfect efficiency in the 
form of a spray from one of Siegel's spray producers. Lime-water, alone 
or with carbolic acid (twenty drops to the ounce of lime-water), liq. potassse 
(twenty drops to the ounce of water), boracic acid (a scruple to the ounce), 
lactic acid (twenty-six grains to the ounce), benzoate of soda (one scruple 
to one drachm to the ounce), all these are of service, and the addition of 
glycerine (half a drachm to the ounce) increases the efficacy of the solu- 
tions. Lotions of chlorate of potash (ten grains to the ounce) and of 
salicylic acid (three or four grains to the ounce) are praised by some, as 
well as dry insufflations of flour of sulphur, of alum, and of tannin. These 
latter have, however, the disadvantage that they cannot be employed with- 
out distressing the patient. If thought more desirable, any of the above 
liquid preparations may be used with a brush, but this method of em- 
ployment is distressing, and except perhaps in the case of infants, presents 
no special advantage. 

The third indication, viz., to destroy the poisonous products of putre- 
faction so as to prevent absorption and blood contamination, is partly 
affected by the use of many of the preceding agents. But besides these, 
special disinfectants may be sprayed into the throat, such as the solution of 
chlorinated soda or lime diluted with water (half a drachm to the ounce), 
permanganate of potash (five grains to the ounce), sulphurous acid, pure 
or diluted with an equal quantity of water, etc. The comfort of the patient 
is also promoted by the use of the steam kettle, as already recommended, 
and by warm applications externally to the throat. If the child be old 
enough, he may be allowed to suck lumps of ice. 



DIPHTHERIA — TREATMENT — TRACHEOTOMY. 105 

In nasal diphtheria, where septicemia is especially to be dreaded, the 
thorough cleansing of the nasal passages with a mild disinfecting solution 
should never be omitted. The importance of this measure is insisted upon 
by Dr. Jacobi, who recommends that the process should be carried out by 
the fountain syringe wherever practicable. Failing that, an ordinary ear 
syringe can be made use of. He directs that the injection should be re- 
peated as often as every hour, and that if the obstructed nostrils resist the 
passage of fluid, the coarser matters must be removed by a probe or 
forceps. Dr. Jacobi states that these injections, efficiently employed, give 
great relief to the patient and rapidly reduce the size of the swollen glands. 
He advises a warm solution of carbolic acid (two to four grains to the 
ounce), or, if there is no fcetor, of lime-water. 

When the disease invades the larynx the danger is at once imminent, 
and the question of operative interference has to be considered. In cases 
of laryngeal diphtheria (true membranous croup), tracheotomy is the only 
hope left to us — the child's last chance for his life. Directly, therefore, 
we feel sure that the larynx is involved, the operation should be under- 
taken without unnecessary delay. It must be remembered, however, that 
dyspnoea alone is not always a sufficient indication for this step. As has 
been before explained (see p. 99), lividity and laboured breathing are some- 
times due to an impediment to the circulation of blood through the lungs. 
In such a case there is no want of air, and opening the larynx will bring 
no relief to the child's distress. The signs by which these two very differ- 
ent conditions are indicated have been already enumerated. "When, there- 
fore, we notice that the respiratory movements have become laboured, with 
great recession of the epigastrium and the soft parts of the chest in inspi- 
ration ; that the breathing is hissing and striduLous, the voice whispering, 
and the cough husky and stifled, the operation should be no longer post- 
poned. We have nothing to hope for in delay ; on the contrary, the earlier 
the tube is introduced into the trachea, the sooner will the child's suffering 
be relieved and the better be his prospect of a cure. The success which often 
attends the operation of tracheotomy in membranous croup is very encour- 
aging, and even in the case of an infant we should not hesitate to have re- 
course to it. Even at a later stage, when the child seems to be at the last 
gasp, the operation should still be undertaken, for nothing short of actual 
death can render it hopeless. 

In performing the operation, if the asphyxia is far advanced anaesthetics 
will be unnecessary. If the lividity is not marked, chloroform should be ad- 
ministered, and if the child be made to inhale it gradually so that he does 
not breathe in too large a volume at first, the anaesthetic may be given 
without fear. The details of the operation, as they come under the depart- 
ment of the surgeon, need not be here referred to ; more especially as they 
will be found recorded at length in all works on practical surgery. It may 
be only remarked that the size of the tube to be employed should be the 
largest which can be introduced without violence ; that it should be as 
short as is consistent with safety ; and that before its introduction the tra- 
chea and larynx must be thoroughly cleansed by introducing a feather 
soaked in a warm solution of carbonate of soda through the opening. The 
importance of this precaution has been strongly insisted upon by my col- 
league Mr. Parker in his well-known treatise. 

The relief afforded by the operation is usually complete. If the diffi- 
culty of breathing still continues, it' is a sign that the trachea is obstructed 
below the opening, and that there is probably extension of the false mem- 
brane far down the ramifications of the bronchi. 



106 DISEASE IN CHILDREN. 

The after-conduct of these cases is of the utmost importance, as success 
depends upon judicious nursing and scrupulous attention to small points 
of treatment. Our object is to furnish a constant supply of properly pre- 
pared air to the lungs. The utmost care has therefore to be taken to 
maintain the inspired air at a suitable temperature and degree of mois- 
ture, and to see that the tube is kept in j:>lace. Moreover, the strength of 
the child has to be supported, and the treatment of the constitutional dis- 
ease to be continued. 

The child should remain in his tent bedstead, in a room of the temper- 
ature of 70° ; and the croup-kettle must be kept in action on a side table 
so as to moisten the air he breathes. A disinfectant should be always ad- 
ded to the water in the boiler, as already directed. The kettle must not be 
placed too near the bed. If the air is kept constantly saturated with va- 
pour, the excess of moisture tends to depress the child. Mr. Parker's rule 
is a good one, viz., that we should be guided by the amount of tracheal 
secretion. If this is small, the amount of steam can be increased. 

The wind-pipe and tracheotomy tube must be kept patent. Free se- 
cretion is to be desired, but this must not be allowed to accumulate so as 
to interfere with the passage of air. It is important to apply weak alkaline 
solutions, such as the bicarbonate of soda (ten to twenty grains to the 
ounce) with a hand spray-producer at short intervals, so that the inhaled air 
may be saturated with the solvent. The spray at once produces free secre- 
tion into the windpipe ; and the repeated use of this agent prevents the 
mucus from accumulating and becoming inspissated so as to block up the air- 
passages. It is curious to notice how the dry mucous membrane becomes 
almost instantly relieved by this means. After a few minutes' use of the 
spray, a feather soaked in the same solution must be passed into the trachea 
through the silver tube, so as to clear away loosened membrane and mucus. 
The introduction of the feather causes spasmodic cough, but this is not 
to be regretted, as the violent expulsive action usually relieves the patient of 
large portions of membrane, and greatly aids in clearing the trachea. If 
signs of obstructed breathing are noticed at any time, we may conclude 
that either the trachea or the tracheotomy tube is becoming obstructed, or 
that the latter is displaced. Measures must then be taken at once to rem- 
edy the fault. 

The inner tube should be removed every hour or two and cleaned with 
a feather dipped in the warm alkaline solution. The outer tube will re- 
quire cleaning only once in the twenty-four hours. When it is removed, 
advantage should be taken of the opportunity to pass the moistened feather 
upwards into and through the glottis, so as to clear the upper part of the 
windpipe. At this time, also, the wound can be examined for any un- 
healthy appearance. As a rule, the outer tube can be easily taken out and 
replaced, for the tissues around the opening soon become matted to- 
gether by inflammatory exudation, and the orifice remains patent after 
the tube is withdrawn. After each cleaning the tube should be replaced 
by another of different length, so that the child may wear a short and a 
long tube alternately. If the tube be of silver, it should be examined for 
black discolourations, as these are due to morbid action at the corre- 
sponding part of the wound, and will therefore, as Mr. Parker has pointed 
out, be often valuable guides in indicating the parts to which our attention 
should be directed. 

After a few days, when fresh membrane has ceased to be formed, we 
may make trial from time to time of the child's power of breathing through 
the glottis by closing the external wound with a finger. At first the 



DIPHTHERIA — TREATMENT. 107 

breathing is laboured, especially in inspiration, but in most cases the 
glottis soon becomes accustomed to act again as an air-passage. 

While the above treatment is being carried out, the strength of the 
child must be supported by judicious feeding. Strong meat essence, 
pounded meat, eggs, milk, strong meat broths thickened with arrowroot 
or sago, and flavoured if desired with turnip, should be given at regular 
intervals. Sometimes there is difficulty in persuading the child willingly 
to take sufficient nourishment ; and sometimes the power of swallowing is 
impaired from paresis of the muscles of the pharynx. Sometimes, also, 
there appears to be loss of sensibility of the glottis, so that articles of food 
taken appear at the wound in the air-pipe. If necessary, therefore, food 
must be conveyed to the stomach by an elastic tube passing through the 
nose (see Introductory Chapter, page 15). By this means the patient can 
be fed efficiently every three or four hours. Internal remedies, with the 
exception of alcohol, are better discontinued at this time. It is wiser to 
limit ourselves to the local measures which have been described for the 
relief of the local disease, and to trust to regular feeding and alcohol to 
support the strength of the patient and enable him* to struggle successful- 
ly against the constitutional disorder. 

The tracheotomy tube should not be allowed to remain in the trachea 
a day longer than is necessary ; for besides that it is not well to allow the 
glottis to continue a long time inactive, too persistent retention of the tube 
may be followed by ulceration about the wound, necrosis of the rings of 
the trachea, and other accidents. In finally closing the wound certain dif- 
ficulties are sometimes met with. The child having become accustomed to 
the use of the tube, and having a keen recollection of his sufferings before 
its insertion, is often nervous and apprehensive of a return of his dyspnoea. 
This very dread may be sufficient to interfere with the normal action of 
the laryngeal muscles. Before removing the tube altogether many at- 
tempts should be made, by withdrawing it temporarily and closing the 
opening with a pad of lint, to accustom the child to breathe without its 
help. He should be also made to articulate under the same conditions (i.e., 
while the opening is closed), so as to bring the muscles of his larynx again 
into action. 

The accidents which often interfere seriously with the final withdrawal 
of the tube are : inflammatory hypertrophy of the vocal cords, adhesion 
between the cords, granulations growing from the tracheal wound or 
from the posterior wall of the windpipe, paralysis of the posterior crico- 
arytenoid muscles, spasm of the glottis, cicatricial narrowing of the trachea. 
Sometimes it is only after much difficulty that the proper function of the 
disused larynx is restored. Such cases are, however, exceptional. Usually 
after a few days the child becomes accustomed to do without the help of 
the tube and all apprehensions of a return of his dyspnoea may be laid 
aside. 

The chief danger and common cause of death after tracheotomy in 
membranous croup is the occurrence of pneumonia. If this unfortunate 
complication arise, warm poultices must be kept constantly applied to the 
chest, and stimulants must be given freely. 

If diphtheria of the external wound occur, it is best treated by a care- 
ful attention to cleanliness, and by painting the wound with a solution of 
lactic acid (twenty-four grains to the ounce). 

In the paralysis which often follows diphtheria the child should be re- 
moved to a bracing sea-side residence, and while there should be regularly 
shampooed and be given baths of the sea-water. If a dip in the sea is too 



108 DISEASE IN CHILDREN. 

vigorous a shock for his weakened frame, the douche may be employed in 
the house after suitable preparation, as directed elsewhere (see Introductory 
Chapter, page 17). Quinine, iron, and strychnia are useful in these cases, 
and the child should pass as much time as possible out of doors. Kegular 
faradisation is of service, especially in cases where the loss of power affects 
the muscles of the larynx or those employed in respiration. In cases where 
there is complete paralysis of the muscles of deglutition, and consequent 
inability to swallow, the child must be fed regularly with the stomach-tube 
passed through the nose. At the East London Children's Hospital many 
children have been saved by this means who were quite unable to take 
nourishment, and who without this help would certainly have died of in- 
anition. 

When a thrombus forms in the heart and gives ries to serious dyspnoea, 
the child should be kept lying doivn ; hot bottles should be applied to his 
feet and if necessary to his sides ; and diffusible stimulants must be given 
internally. Dr. Richardson speaks highly of the liq. ammonite (P. B.), of 
which a few drops may be given with five grains of iodide of potassium 
every alternate hour. If the heart's action appear to be failing, stimulants 
in large and repeated doses are indicated. 



CHAPTER XI. 

ERYSIPELAS. 

Erysipelas is not often seen in childhood after the age of infancy has 
passed. For a short time after birth, however, there appears to be a special 
tendency, under favouring conditions, to suffer from this serious affection ; 
and in lying-in hospitals the disease is a not unfamiliar one. Amongst 
well-to-do families erysipelas but rarely attacks the infant, and in chil- 
dren's hospitals, even in those where quite young infants are admitted, it 
is exceptional to meet with an example of this form of illness. 

Causation. — Erysipelas is in all cases a general disease of which the 
dermatitis and its consequences are merely the local expression. The 
malady most commonly affects new-born babies at a time when puerperal 
fever is prevalent, and is most liable to happen during the first six weeks 
of life. It is then apparently the result of a similar affection to that which 
attacks the mother ; and the illness almost invariably has a fatal issue. 
According to Trousseau, besides erysipelas, purulent ophthalmia and in- 
fective peritonitis are common under the same conditions, and the three 
diseases must be regarded as various manifestations in different subjects 
of the same morbific principle. 

But besides special puerperal infection, other agencies will act as pre- 
disposing causes of the affection. Unhealthy conditions generally will do 
this ; and the complaint has been known to follow exhausting derange- 
ments and diseases, such as chronic digestive troubles and the acute spe- 
cific fevers. In some cases, however, no such influences can be discovered 
to have been in operation. Such a case came under my own observation 
in my student days. A healthy infant of a week old had great difficulty 
in relieving his bladder, owing to a very narrow preputial orifice. The 
operation for circumcision was performed (not very wisely) by a young 
surgeon. Extensive erysipelas followed, starting from the wound, and in 
a few days resulted in the death of the patient. The child was being- 
suckled by a healthy mother. The parents were of the poorer class, but 
seemed comfortably circumstanced ; and their residence was clean, sjmL 
certainly presented no obvious insanitary conditions. Possibly in tms 
and similar cases the erysipelas owed its origin to the use of imperfectly 
cleansed instruments in the operation. 

The exciting cause of the affection is usually traumatic. The erysipelas 
may follow the operation of vaccination, inflammation set up about the 
umbilicus, a bum, or the incautious application of a blister. It may de- 
velop around an intertrigo or attack a surface excoriated by the irritation 
of excreta. Some time ago a local outbreak of erysipelas occurring in a par- 
ticular London district was traced to the use of a violet powder extensively 
adulterated with white arsenic. Apparently idiopathic cases do, however, 
sometimes occur. Thus, Mr. Strugnell has reported the case of a male in- 



110 DISEASE IN CHILDREN - . 

fant, aged eight weeks, in whom a patch of erysipelas appeared on the 
scalp and thence spread to the face, arms, and trunk. The child had suf- 
fered from no bruise or other injury, and nothing objectionable was dis- 
covered in the sanitary state of the house in which his parents were living. 
Other cases of a similar kind are on record. 

It seems possible that the milk of a mother who has lately suffered from 
erysipelas may communicate the disease to her sucking child. Dr. Schole- 
field has reported a case in which a woman during a sharp attack of ery ■"' 
sipelas of the face, neck, and scalp, gave birth to a son. As the labour 
progressed the erysipelas gradually faded, and when the child was born no 
trace of redness remained. The mother was warned not to nurse her 
child ; but on the fourth day, as the secretion of milk was copious, she 
put the infant to the breast. Twelve hours afterwards a red blush ap- 
peared on the child's thumb and spread to the arm. This faded and the 
opposite arm became affected in the same way. Afterwards the same 
symptom appeared on one of the lower limbs, and in the end a large ab- 
scess formed over the sacrum and the child died. The mother had no re- 
turn of the erysipelas after delivery. 

This was not a case of puerperal erysipelas in the mother, for the dis- 
ease had not only preceded labour but had completely disappeared by 
the time the child was born. It seems probable that the poison was com- 
municated by the mother to the infant through the milk from her breast. 
At any rate, it is difficult to say in what other way the infant could have 
contracted the disease. 

Morbid Anatomy. — In the skin the inflamed surface is red, hard, and 
brawny, with a well-defined margin. The redness disappears on pressure, 
and the hardness is due to accumulation of serum, lymph, and corpuscles 
in the substance of the cutis and tissue beneath it. If the oedema be co- 
pious, the part is dull red in colour, soft to the touch, and pits on pressure. 
The area of inflammation rapidly extends to neighbouring parts, and as it 
spreads the skin first attacked becomes less tense and browner in colour. 
Sometimes the skin affection disappears from one part of the body and 
reappears on another without spreading along the surface. Thus, it may 
attack one limb, then fade in its first situation and break out on the cor- 
responding limb of the opposite half of the body. 

As a result of the inflammation, abscesses may form in the subcutane- 
ous tissue ; and sometimes sloughing may occur in the skin or areolar tis- 
sue. Often vesicles or bullae form on the inflamed surface, especially in 
the severe cases where there is subcutaneous sloughing. 

In most instances of erysipelas in the infant, adjacent parts share in the 
inflammation of the skin. Peritonitis is common, even when the dermatitis 
does not occupy the abdominal parietes. There may be also inflammation 
of other serous membranes — the pleura, the pericardium, and the cerebral 
meninges. Sometimes the inflammation spreads from the skin to other 
parts by direct continuity. Thus, it may pass into the ear by the auditory 
meatus, into the nose and throat by the mouth, nares, and lachrymal ducts. 
In other cases, the disease begins in these deeper parts and extends to the 
skin by the same channels. In addition to the above morbid appearances, 
evidence of phlebitis, pneumonia, and enteritis is often observed. Lately 
micrococci, arranged in clusters, have been discovered by Fehleison in the 
lymphatic vessels of the affected portions of the skin. This observer has 
even succeeded in artificially cultivating the organisms on gelatine, and in 
the course of two months reared fourteen generations of micrococci. Some 
of these cultivated micro-organisms he inoculated into animals and others 



ERYSIPELAS— MOEELD ANATOMY— SYMPTOMS. Ill 

into the human subject. In almost all cases a typical erysipelas followed 
the operation in the person or animal experimented upon. 

Symptoms. — The disease presents different characters according to 
whether it arises as a consequence of puerperal infection or is induced by 
other causes. 

In the first case the general symptoms are usually violent from the 
first. A patch of bright redness appears on some part of the abdomen, 
usually about the pubes. The part looks somewhat swollen, feels hard 
and brawny, and has a well-defined margin. The patch may be of limited 
extent, but there is high fever, and the infant looks ill, is restless, cries 
frequently, and is evidently in great pain. By the next day the area of 
redness has become widened ; the fever continues ; the fontanelle is de- 
pressed, and the patient sleeps little and is very restless and feeble. The 
erysipelas continues to extend. It passes downwards to the lower limbs 
and upwards over the trunk ; the belly usually becomes fuller and may be 
tympanitic ; vomiting and diarrhoea come on, and a jaundiced hue of the 
skin may be observed. After a few days, the child falls into a state of 
collapse and death may be preceded by convulsions and coma. In this 
form of the disease the duration is sometimes very short. A child who 
appears to be healthy and vigorous when first attacked rapidly falls into a 
state of prostration and may die in a few days. The illness may, however, 
last for a longer time. The colour of the inflamed surface then becomes 
deeper and more purple, bullae appear on the surface, abscesses form in 
the subcutaneous tissue, or gangrenous sloughs may destroy considerable 
portions of the skin. Infants attacked by the puerperal form of erysipelas 
are usually under two weeks old, and the illness is almost invariably 
fatal. 

When erysipelas occurs as a result of other causes than puerperal in- 
fection the early symptoms are less violent. The local affection generally 
begins about the genitals, the pubes, the anus, or the lower part of the 
abdomen, and spreads thence in various directions. "When it extends 
widely, the parts of the skin first affected become paler, but are liable at 
any time to a return of the redness. The child has a pale pinched face, 
but may continue to take his food, and his digestion is often fairly good. 
In other cases, he refuses the bottle or breast, and may be troubled with 
frequent vomiting or looseness of the bowels. The temperature is high, 
at night it rises to 103° or 105°, sinking to 101° or 102° in the morning. 

Complications often occur in these cases. Abscesses may form in 
various parts of the body ; gangrenous sloughing may attack the skin ; 
pneumonia may occur ; or the inflammation may pass directly to the peri- 
toneum through the recently healed umbilicus, or to the larynx and throat. 
An infant under six months old was brought to St. Thomas' Hospital and 
admitted, under Mr. Croft, for erysipelas following vaccination. When 
seen, the whole cervical region and part of the chest were the seat of cede- 
matous erysipelas, and there was great dyspnoea without symptoms of 
croup. The child was placed in a warm bath and a dose of ipecacuanha 
wine was given to produce vomiting. These measures relieved the child 
for a time, but in the evening the dyspnoea returned with such intensity 
that tracheotomy was performed by the Surgical Registrar. After the op- 
eration the infant coughed up small pieces of cartilage — probably from the 
rings of the trachea. Eventually he recovered. 

Whether the disease be idiopathic or arise from traumatic causes its 
gravity appears to be the same. In the first case the appearance of the 
special symptoms is often preceded by signs of derangement or sluggish- 



112 DISEASE m CHILDREN. 

ness of the digestive organs. In Mr. Strugnell's case, before referred to, 
an infant of eight weeks old had been a fairly healthy child, but for ten 
days or so had been passing very firm, pale, pasty-looking motions. The 
child was suddenly taken with severe symptoms, and when first seen was 
lying with his head thrown back and his thumbs twisted inwards upon 
his palms, but there was no retraction of the abdomen or strabismus. 
The pupils were equal and acted to light, the pulse was rapid, the temper- 
ature was normal. On examination slight oedema of the scalp was noticed 
on the occipital bone, but there was no redness. On the next day the 
cedematous part was red. On the third day the cerebral symptoms had 
subsided ; but the erysipelas had spread to the forehead and down the 
back of the neck. Afterwards it extended over the face, arms, and trunk. 
A vesicle the size of a filbert and filled with clear serum formed over the 
left elbow, and another appeared a little later on the thigh. As the dis- 
ease advanced, the abdomen became distended and tympanitic, and the 
breathing oppressed. No mischief was discovered in the chest. The child 
sank and died on the seventh day. 

In this case the early cerebral symptoms (retraction of the head and 
twisting in of the thumbs) were probably symptomatic of the general dis- 
ease and not of any special intra-cranial complication. They were of short 
duration and quickly disappeared when the skin affection became marked. 
The tympanites and embarrassment of breathing were, no doubt, due to the 
occurrence of peritonitis. Premonitory symptoms, such as were found in 
the above instance, are not common. Usually the first indication of ill- 
health is the occurrence of the cutaneous redness and swelling. 

In traumatic cases the duration of the disease is often considerable. 
The illness may last two or three weeks, or even longer. Eecovery is not 
a frequent termination, and usually death is brought about by one of the 
many complications to which these cases are liable. If none' of these occur, 
the case may end favourably, even although the erysipelas has spread ex- 
tensively and involved the greater part of the surface of the body. The 
subsidence of the cutaneous inflammation is followed by desquamation of 
the epithelium in the portions of skin affected. 

Diagnosis. — The nature of the disease can scarcely be misapprehended. 
A patch on the skin of bright redness, which feels brawny to the touch and 
is perhaps cedematous, spreads continuously over the surface, and is bounded 
by a well-defined margin — these local symptoms combined with the severe 
general disturbance and high fever, make the diagnosis of erysipelas an 
easy matter. 

Prognosis. — When erysipelas occurs in an infant of a week or fortnight 
old, as a result of puerperal infection, the prognosis is most serious. Very 
few of these cases recover, although Trousseau has stated that in cases 
where abscesses have formed extensively, and in these cases only, he has 
known life to be saved. Consequently he regarded the occurrence of ab- 
scesses as by no means an unfavourable symptom. 

When the disease arises as a result of other causes the child's pros- 
pects are more hopeful, and are brighter in proportion to his age, his 
general strength, and the healthfulness of his surroundings. Of forty- 
three cases collected by Dr. Lewis Smith eighteen recovered ; but of the 
cases of recovery in only one was the child younger than three months. 
If the disease attack an infant during the first two or three weeks after 
birth, death is almost certain. After the age of six months the proportion 
of recoveries is greater than that of the deaths. 

In all cases the occurrence of a serious complication greatly reduces the 



ERYSIPELAS— TREATMENT. 113 

child's chances of escape, and if peritonitis occur, we can have little hope 
of a favourable issue. 

Treatment. — In cases where the disease arises from puerperal infection 
treatment has been found of little value. Alcoholic stimulation and the ad- 
ministration of ammonia and bark may be useful in supporting the 
strength, but local treatment of every kind appears to be useless. It 
would be advisable in these cases to make trial of benzoate of soda — a salt 
which has been highly praised by Dr. Lehnebach for its value in puer- 
peral fever in the adult. Two or three grains might be given to a child of a 
week old every four hours, and if the fever were very high, one or two grains 
of quinine might be added once in the day to a dose of the benzoate. 

In cases where no puerperal infection is suspected, the child should be 
made to take the tincture of perchloride of iron in frequent doses. For an 
infant of three months old five drops of the remedy may be given in gly- 
cerine every four hours. At the same time the strength should be sup- 
ported by a careful diet. If the child be at the breast, the mother's milk 
is no doubt the best food he can take. In addition, he may have a tea- 
spoonful of the brandy-and-egg mixture two or three times a day if his 
fontanelle is greatly depressed. As long, however, as the strength contin- 
ues good there is no necessity for stimulation. If the patient be hand-fed, 
care should be taken that his milk is diluted with barley-water or thickened 
with gelatine ; and the stools must be inspected to see that undigested 
curd is not passing away from the bowels. If this be so, the milk should 
be diluted with half its bulk of barley-water or aq. calcis ; and should be 
aromatised by the addition of two teaspoonsful of an aromatic water to the 
bottle. Mellin's food, white wine whey, etc., may also be given. 

With regard to local treatment, innumerable applications have been 
recommended. Most of these are sedative or antiseptic. Thus, the in- 
flamed part may be anointed with an ointment composed of equal parts 
of extract of belladonna and glycerine, and covered with cotton wool. The 
application of oil of turpentine has been recommended by Hastreiter. 
Cavazzani speaks highly of brushing the surface with a lotion composed of 
one part each of camphor and tannin to eight parts of ether. Painting 
with tincture of iodine is advocated by some, and with a solution of car- 
bolic acid by others. Heppel states that the spread of the inflammation 
may be limited by painting the skin at the circumference of the patch, and 
for a finger's breadth on each side of it, with a ten per cent, solution of 
carbolic acid. The brush should be used until a distinct staining of the 
integument has been produced. The plan recommended by Hueter, of in- 
jecting subcutaneously around the margin of the patch a three per cent, 
solution of carbolic acid, is inadmissible in the case of a young child, in 
whom symptoms of carbolic acid poisoning would be easily produced. En- 
deavors to limit the spread of the erysipelas, by a line drawn on the skin with 
nitrate of silver just beyond the margin of the inflamed patch, have been 
found to be useless. In the child such a proceeding is to be strongly dep- 
recated, as its employment has been sometimes known to lead to the for- 
mation of troublesome sores upon the surface. 

An important element in the treatment appears to be covering the in- 
flamed surface from the air. Kecently, Mr. Barwell, reviving an old 
method, has found the utmost benefit to result from covering the affected 
area with a thick coating of common white lead house-paint, renewing the 
application as often as any crack appears on the surface of the paint. This 
plan of treatment seems not only to relieve the pain quickly, but also to 
reduce the temperature and favourably influence the general symptoms. 
8 



CHAPTEK XII. 

WHOOPING-COUGH. 

Whooping-cough, or pertussis, is an infectious disorder in which catarrh of 
the air-passages is combined with nervous symptoms which may assume 
very serious proportions. The affection occurs in epidemics and may at- 
tack the youngest infants : indeed, sometimes it appears immediately after 
birth. In such young children whooping-cough, even when not of a grave 
type, may cause serious consequences. It is principally dangerous, how- 
ever, through its complications. These are numerous, and often appear 
towards the end of the disease, when the patient's strength is reduced by 
the length and severity of his illness. 

Causation. — The disease usually occurs in epidemics, and appeal's to be 
eminently infectious. The channel of infection is the breath and expecto- 
ration ; and the virus is capable of being conveyed by the atmosphere or 
even by the clothes. Children of all ages are very susceptible to the infec- 
tious principle. The disease is excessively common under two years of 
age, very common, even, during the first twelve months. Unfortunately, 
I have kept no systematic record of the many cases of whooping-cough 
which have passed under my notice, but in eighty-nine cases of which I 
have preserved notes no less than twenty-four occurred in infants during 
the first year of life. Even this proportion probably represents imperfectly 
the frequency of the disease in young babies ; for in such subjects the 
spasmodic stage is often absent. Dr. E. J. Lee is of opinion that infants 
suffer from pertussis much more frequently than is supposed, and asserts 
that in a very young child a whoop ought rather to excite surprise than to 
be looked upon as an ordinary symptom. This is, perhaps, an extreme 
statement, but there is no doubt that in infants the disease frequently as- 
sumes the form of an obstinate pulmonary catarrh with but little laryngeal 
spasm. After the tenth year the disease becomes very rare ; but it may be 
seen at any time of life, even, as is well known, quite at the close of ex- 
treme old age. 

Whooping-cough seems to be more common in the spring and autumn 
than in the other seasons of the year, and the epidemic is often found to 
precede or to follow quickly upon an epidemic of measles. A patient who 
has passed through one attack of whooping-cough is in little danger of his 
illness being repeated, for a second attack in the same subject is rare. 
The infection, however, lasts for a considerable time after the whoop has 
ceased to be heard. Dr. Squire is of opinion that at least six weeks should 
be allowed to elapse before the patient can be trusted to associate with 
healthy children. 

Pathology. — Examination of the body in a fatal case of pertussis reveals 
nothing to account for the special nervous symptoms which impart its most 
characteristic feature to the disease. We find signs of catarrh of the air- 
passages, viz., congestion with hypersecretion of the mucous membrane 



WHOOPING-COUGH — PATHOLOGY — SYMPTOMS. 115 

within the glottis, of the trachea, and of the bronchi and their ramifica- 
tions. We also find certain consequences produced by violence of cough 
and spasm, viz., pulmonary collapse and emphysema. In addition, we 
usually meet with some other morbid changes due to the complication by 
means of which the fatal issue has been brought about. Thus, there may 
be serious congestion and even extravasation of blood into or upon the 
brain, and sometimes signs of thrombosis of the intracranial sinuses, 
shown by colourless clots of laminated structure adhering to the walls. 
The lungs may be the seat of catarrhal pneumonia, and occasionally small 
extravasations are seen here as in the brain. Moreover, there is almost in- 
variably enlargement of the bronchial glands, and the under surface of the 
tongue may be ulcerated more or less extensively. 

No satisfactory explanation has yet been given of the real nature of the 
complaint. That the disease is due to inflammation of the pneuniogastric 
nerve has been shown to be erroneous. Pressure upon the same nerve by 
enlarged glands may be rejected for the same reasons which render this 
explanation of the phenomena of laryngismus stridulus an insufficient one. 
In some respects the affection resembles a zymotic disease ; in others a 
neurosis. Some writers consider the complaint a purely catarrhal one ; 
others lay most stress upon the nervous symptoms. That the disease is 
something more than a mere catarrh is shown by the infectious nature of 
the secretion thrown off by the mucous membrane. In 1870 Letzerich 
believed he had discovered a species of fungus in the sputum, and sup- 
posed that this was the morbid material which, carried from one person to 
another, settled upon the mucous membrane of the air-passages, and by 
its irritation gave rise to the spasmodic symptoms. Other observers, 
however, have not confirmed this alleged discovery. More lately Dr. 
Carl Burger, of Bonn, has described a bacillus which he has found in the 
expectoration of children suffering from whooping-cough, and states that 
it is peculiar to this complaint. 

The neurotic character of pertussis is shown not only by the laryngeal 
spasm, but by the violent agitation into which the child is thrown during 
a paroxysm. When he feels the desire to cough becoming irresistible he 
clutches at his mother's dress or the nearest object capable of giving sup- 
port, and his whole body is agitated by a convulsive trembling. This agi- 
tation is usually attributed to terror, but it is more probably the conse- 
quence of a general nervous commotion which, carried to a higher pitch, 
may become a genuine convulsive seizure. A distinguished physician who 
was attacked by whooping-cough after middle life, in describing the ner- 
vous agitation induced by the spasm, assured me that in the paroxysm he 
required all his self-control to avoid beating with his feet upon the floor. 
It seems, therefore, that the neurotic element of the disease is something 
more than a mere nervous spasm of the larynx and diaphragm. There 
appears to be a general agitation of the whole nervous sj-stem, which may 
be more or less pronounced according to the severity of the attack and 
the inherent susceptibility of the child. 

Symptoms. — The incubation period of pertussis is difficult to ascertain 
on account of the uncertainty as to the exact day upon which the disease 
can be said to begin. It has been estimated at from two to seven days. 
Other observers are of opinion that it may last a fortnight. 

When the disease begins we find the symptoms of catarrh of the air- 
passages. The eyes are slightly iujected, there is snuffling and increased 
secretion from the nose, and the child soon begins to cough. There is 
some fever, the temperature usually rising to 100°, and the pulse is 



116 DISEASE IN CHILDREN. 

quickened. In a day or two there may be in addition some increased 
rapidity of breathing. If the catarrh affect the gastric mucous membrane, 
there is loss of appetite and the child may be languid and mope. The 
symptoms resemble those of an ordinary catarrh, but their specific charac- 
ter may be sometimes detected by noticing the unusual obstinacy of the 
cough. It is repeated at very short intervals, and sometimes is almost in- 
cessant. This catarrhal stage lasts for a variable time. It may occupy 
only a few days or may be continued for several weeks. The symptoms 
usually increase in severity as the days go by. The cough becomes more 
troublesome, and is worse at night than in the day. If the child is old 
enough he complains of a harassing tickling in the throat ; and there is 
often violent sneezing, with the ejection of much ropy mucus from the 
nose. 

After a time a change in the character of the cough shows that the 
spasmodic stage has begun. The cough occurs in paroxysms, and has 
such a distinctive character that it at once betrays the nature of the child's 
complaint. It consists in a number of short hacks, following so rapidly 
upon one another as to allow of no inspiratory effort. As these continue, 
the child's face turns from red to purple, and seems to swell and darken 
at the same time. At length, when the lungs are almost exhausted of 
their air, and the patient seems upon the very point of suffocation, air is 
at last drawn in with a long, deep inspiration, accompanied by the charac- 
teristic " kink " or whoop. Immediately, however, the cough begins again ; 
and in this way the long rapid expiratory cough, the signs of imminent 
asphyxia, and the slower whooping inspiration may be repeated several 
times before the expulsion of a large quantity of thick tenacious phlegm 
from the mouth, and perhaps the ejection of food mixed with ropy mucus 
from the stomach, announces the end of the attack. The child, then, if 
an infant, sinks back exhausted and perspiring in his mother's arms, and 
if the cough do not return immediately, usually falls into a heavy sleep. 
An older child seems a little languid, but if the paroxysm has not been 
severe, may return quickly to his amusement. If, on the contrary, the 
spasm has been prolonged, he may seem dull and confused for a time, and 
may complain of headache. 

During the fits of coughing the pulse becomes very rapid, and is almost 
uncountable. If we listen to the back at this time we hear some slight 
wheezing in the large air-tubes during the expiratory cough ; but during 
the long-drawn inspiration any slight vesicular sound which might be 
heard is covered by the noise of the whoop. In the intervals of the cough 
auscultation in an uncomplicated case merely reveals a few large bubbles 
mixed up with dry wheezing sounds scattered about the lungs. 

When the paroxysms are violent they are a cause of great distress to 
the patient. This is well shown by the efforts a young child will make to 
keep them back. He may be noticed, while on his mother's lap, to hold his 
breath and sit perfectly still in the hope of repressing the cough. When 
he feels that the impulse is getting beyond his control his face becomes 
congested, his brows contract, and sweat breaks out on his forehead ; and 
as the convulsive expiratory efforts begin, he clutches at his mother's dress 
and often trembles all over with nervous agitation. During the paroxysm 
the straining may produce rupture in a child predisposed to hernia ; and 
haemorrhage from the intense congestion induced is a common symptom. 
The bleeding may take place from the eyes, the ears, the nose, the mouth, 
and sometimes from the lungs. Cracks about the lips and sore places on 
the gums almost always bleed during the fits of coughing. Epistaxis is 



WHOOPING-COUGH — SYMPTOMS — COMPLICATIONS. 117 

very common. When haemorrhage occurs from the nose the blood does 
not always flow forwards through the nostrils ; often it passes backwards 
through the posterior nares into the throat. It may be then swallowed 
and discharged as black matter by stool, or be vomited after the next at- 
tack of cough and cause great alarm. In other cases the blood irritates 
the glottis and induces a fresh paroxysm. It is then expelled with the 
cough and is supposed to come from the lungs. 

The number of paroxysms that occur in the twenty-four hours varies 
very much according to the severity of the attack, and partly, too, accord- 
ing to the number of disturbing causes to which the child is exposed. In 
severe cases, where the slightest emotional or other influence will induce 
an attack, the number may be considerably diminished by quiet and judi- 
cious amusement. The child often coughs more in the night than dining 
the day, for the occurrence of the seizures appears to be favoured by the 
recumbent position. Between the paroxysms, when the spasm is violent, 
the child's face may remain permanently congested. The eyes are red 
and often bloodshot ; the eyelids are heavy and swollen ; the face and lips 
are dull red ; there is a dusky tint round the mouth and under the eyes, 
and the veins of the neck are full. 

The attacks themselves vary in character. The whoop may be entirely 
absent throughout the disease. This is said to be common in very young 
infants. The number of expiratory efforts is very variable. Usually there 
are only two or three, but they may be much more numerous. As a rule 
the coughing fits are longer at the beginning of the spasmodic stage, when 
secretion is thinner and less copious, than at a later period, when it becomes 
abundant and more tenacious. After the whoop has lasted a fortnight it 
grows less violent and is less frequently heard. It only occurs with the 
more violent fits of coughing, and in the milder ones the breath is drawn 
more quietly and with greater ease. At the end of three weeks or a month 
it becomes very rare, and the complaint may then be said to have passed 
into the stage of decline. 

The whole time occupied by an attack of whooping-cough varies from 
a fortnight or even less to two months or longer. The duration is often 
difficult to ascertain, for after the spasmodic cough has disappeared and 
the disease has again come to assume an ordinary catarrhal type, trifling 
accidents, such as a chill or an error in diet, may set up more active symp- 
toms, and the whoop may even return for a time. In this way the com- 
plaint may be prolonged for many weeks. 

Complications. — There are certain accidents attendant upon the com- 
plaint which may be a cause of distress or danger to the patient. Sub- 
lingual ulceration is common ; haemorrhage may be copious ; the vomiting 
may greatly interfere with nutrition ; bowel complaints may supervene ; 
the nervous symptoms may be exaggerated ; and various pulmonary dis- 
eases may ensue and, if they do not prove fatal, injuriously affect the future 
welfare of the child. 

The sublingual ulceration has been before referred to. It occupies the 
freenum of the tongue and niay extend for some distance on each side of 
the middle line. The sore may vary from a mere abrasion to a deep fis- 
sure with a gray or yellowish surface. It is only seen in cases where the 
child has cut the lower incisors, and is the direct consequence of the scrap- 
ing of these teeth against the under surface of the tongue as this organ is 
protruded and withdrawn during the paroxysms of cough. Blood often 
exudes from the abraided surface towards the end of a paroxysm. The 
ulcer is not a constant symptom. It never appears before the spasmodic 



118 DISEASE IN CHILDREN. 

stage, but may then be seen as early as the fourth day of the whoop. It 
is most common in infants who have cut the two central lower incisors and 
no other teeth. In children who have cut all their teeth the symptom is 
much less common. 

Hemorrhage must not be looked upon as in every case an untoward 
accident. When the spasm is violent and the congestion of the head and 
face extreme, the relief afforded by a discharge of blood from the distended 
vessels of the nose is no doubt often a salutary incident. If, however, the 
haemorrhage occur frequently and be very copious, great weakness may be 
occasioned ; and if the child be already reduced by the violence of the at- 
tacks and the deficiency of nourishment occasioned by repeated vomiting, 
the loss of blood may be an additional reason for anxiety. Kupture of 
vessels elsewhere than in the nose seldom occurs to any extent. Blood 
ejected from the mouth during whooping-cough comes almost invariably 
from this source. Haemoptysis is rarely seen, for blood coming up from 
the lungs after an attack is usually swallowed by children, and is seldom, 
if ever, sufficiently considerable to be a source of danger. 

Haemorrhage may also occur into the subcutaneous connective tissue of 
the eyelids and that beneath the conjunctiva. The eyes are often blood- 
shot from small ecchymoses, and occasionally we see little extravasations 
in the thickened eyelids. 

Haemorrhage from the ears is the consequence of rupture of the tym- 
panic membrane. Several instances of this accident have been recorded. 
It is occasioned by the blast of air which is forced through the Eustachian 
tube during the fits of coughing, and a certain amount of blood exudes 
from the torn surface. In two out of four cases published by Dr. Gibb 
the rupture occurred in both ears. 

In very rare cases haemorrhage has been noticed in the brain and its 
membranes, causing death. 

Certain digestive troubles may arise. Vomiting at the end of a fit of 
coughing is a familiar symptom. Usually it is of little consequence. If, 
however, the attacks of cough occur very frequently, and are followed in 
each case by sickness, the child's nutrition is visibly affected ; for almost 
all the food taken is vomited before there is time for digestion to begin. 
Even if vomiting is not excessive, there is often considerable interference 
with nutrition, for the catarrhal condition of the gastric mucous membrane 
is ill adapted to further healthy digestion. In many cases, no doubt, the 
tough mucus which coats the wall of the stomach prevents the food from 
being properly mingled with the digestive juices. It is not uncommon, as 
M. Eilliet long ago pointed out, for food to be vomited little changed sev- 
eral hours after a meal. On account of the mucous flux in the bowels 
worms are a frequent complication, and diarrhoea is easily excited. A cer- 
tain amount of looseness of the bowels is present in a large majority of the 
cases of pertussis, and considerable quantities of mucus are passed in the 
stools. 

Nervous accidents form a very important class of complications. Some- 
times the laryngeal spasm is exaggerated. It is not uncommon to see a 
child at the end of the long expiratory cough, instead of at once beginning 
to whoop, remain for some seconds with darkened face, staring eyes, and 
open mouth, making agitated movements and vainly striving to overcome 
the spasmodic contraction which is closing the entrance to his lungs. If 
prolonged the spasm adds greatly to the gravity of the case, and may even 
determine the fatal issue. This is especially likely to happen if the per- 
tussis is complicated with serious lung mischief. In a case which came 



WHOOPING-COUGH — COMPLICATIONS. 119 

under my own notice — a child of seven years of age, both of whose lungs 
were the seat of catarrhal pneumonia — the spasms were very violent and 
prolonged, and in one of them the patient died. In a case recorded by 
Drs. Meigs and Pepper, whooping-cough complicated a case of laryngismus 
stridulus, and the child died in a spasm. Sometimes the patient falls into 
a state of syncope from which he can be roused only with the greatest 
difficulty. 

The semi-asphyxiated state in which the patient is often left after a 
severe paroxysm of cough may be a cause of general convulsions. Eclamp- 
tic attacks, indeed, often complicate pertussis ; but although their occur- 
rence should give rise to great anxiety, the seizures are not necessarily 
fatal. If the convulsion be the consequence merely of deficient aeration of 
the blood, the return of free respiration removes the danger for a time ; 
but if the same condition be frequently renewed, the child's state is a very 
anxious one. So, also, convulsions excited by embolisms or congestions of 
the cerebral vessels, thrombosis of the cranial sinuses, or diffused collapse 
of the lungs, are very serious. These generally occur late in the disease 
and are almost invariably fatal. There are two forms of eclampsia liable to 
happen which are less dangerous. One of these is due to an exaggeration 
of the nervous excitement which is an ordinary symptom of the disease. 
In highly sensitive children it is probably not uncommon for convulsions 
to take place from this cause, especially if the strength has been quickly 
reduced by copious epistaxis. So, also, the onset of an inflammatory com- 
plication is often indicated by a convulsive fit, and these attacks, like the 
preceding, are often recovered from. If, however, a convulsive fit occur 
late in the disease, when there is much consolidation of lung, the child 
seldom recovers. In connection with this subject it is well to remember 
that convulsions occurring in the course of whooping-cough may be due 
only indirectly to that disease. The tendency to eclamptic attacks which 
is common in early life is, no doubt, heightened by the state of ner- 
vous excitement in which the system is maintained by the illness. At any 
rate it is common, especially in rickety children, to find convulsions su- 
pervene in the course of whooping-cough upon very slight gastric or in- 
testinal irritation. Convulsions occurring in pertussis without being 
followed by ill consequences may be, no doubt, often attributed to this 
cause. 

Another important group of complications consists of the pulmonary 
lesions which may occur in the course of whooping-cough. These, on ac- 
count of the nature of the complaint and the tender age of the patient, are 
readily excited, and often bring the illness rapidly to a close. In fact, the 
liability to these accidents constitutes in most cases the chief danger of the 
disease. 

Collapse of the lung is one of the commonest and most fatal of these 
complications. In a severe case of whooping-cough in a young child this 
accident may happen at any time. Indeed, it may be said that at the end 
of every violent paroxysm of coughing the patient is threatened with col- 
lapse of the lung, for all the conditions which conduce to this disaster are 
present together. Thus the spasmodic cough almost empties the lungs of 
ah' ; the ropy mucus in the tubes offers an obstacle to its re-entrance ; and 
the state of exhaustion in which the patient is left weakens the force of the 
inspiratory act. The mechanism of collapse of the lung and the symptoms 
and signs which result from it are described at length in another place. 
It will be sufficient here to remark that the occurrence of collapse is often 
indicated by an attack of convulsions, and if the area of lung affected be 



120 DISEASE IN CHILDEEN. 

large, sudden death may even ensue. In the less serious cases the child lies 
back with his head low ; his face is pale or slightly livid and covered with 
a cold sweat ; the eyelids and lips are dull red or purple ; the nares act, 
and the respirations are frequent and shallow. There is no fever ; often 
the temperature is lower than natural. On examination of the chest we 
find a little dulness at one or both bases behind ; the breathing is bron- 
chial, and sometimes loose crackling rhonchus may be heard at the lower 
part of each lung. The whoop generally ceases when collapse occurs, but 
the fits of coughing continue, although in a modified form, and add greatly to 
the exhaustion of the patient. These cases almost invariably end in death. 
The child lies quietly, as if unwilling to stir a muscle. He takes food with 
difficulty and seems afraid to swallow. If lifted up suddenly he may die 
from syncope : often the end is preceded by a convulsion. 

Bronchitis and catarrhal pneumonia are other common consequences of 
whooping- cough. The pulmonary catarrh, which is one of the characteristic 
features of the disease, is easily aggravated, and readily invades the smaller 
tubes of the lung. In a young child, too, a bronchitis seldom remains a 
bronchitis, but the inflammation quickly travels to the fine bronchioles and 
air- vesicles. Thus a catarrhal pneumonia is easily set up. In a severe 
case of pertussis the breathing becomes more and more oppressed and the 
face more and more livid as the catarrhal inflammation extends itself ; but 
when the terminal tubes are reached and catarrhal pneumonia begins, the 
change is at once announced by new symptoms. The whoop ceases ; the 
temperature rises to 102° or 103 ° ; the breathing is quickened and laboured, 
and the pulse-respiration ratio is perverted ; the face is livid ; the nares are 
wddely expanded. Although there may be no percussion dulness, a physical 
examination of the chest reveals some of the signs connected with this dan- 
gerous condition. Sometimes a fit of convulsions ushers in the complication. 
If the pneumonia be extensive the child generally dies. If it be moderate, 
and the attack of whooping-cough be nearing its close, he may recover, 
but his life may be said to hang on a thread, for the occurrence of a little 
collapse, still further reducing the amount of breathing space left to him, 
may at once determine the fatal issue. 

Emphysema of the lung, which often occurs, is a complication of little 
gravity. It usually occupies the upper lobes and anterior borders of the 
lungs. It is produced mechanically by forcible distention of the air-vesi- 
cles, air being driven from the lower parts of the lungs into the upper por- 
tions during the spasmodic cough, or rather during the violent contrac- 
tions of the diaphragm which immediately precede the cough when the 
glottis is closed. In the severer cases there is some dilatation of the 
smaller bronchi as well as of the air-cells. The condition is an acute one, 
and usually subsides when the disease passes off. In scrofulous children, 
however, it may remain as a permanent lesion. 

Of these complications emphysema is one of early occurrence. Col- 
lapse and catarrhal pneumonia occur late in the disease, as a rule, when 
the child's strength is reduced and his nutrition impaired. 

Besides the above accidents others may occur. Laryngitis is seen 
sometimes, but if not severe adds little or nothing to the danger of the 
case. Pleurisy and pericarditis are occasionally found, but these do not, 
like the preceding, follow naturally from the complaint, and are not often 
met with. 

Sequelce. — When the disease has passed off consequences, local and 
constitutional, may be left behind. Any diathetic taint, previously dor- 
mant, is often roused into activity. Scrofulous children may become subject 



WHOOPIXG-COUGH— SEQUEL M. 121 

to chronic discharges, inflammations, and other signs of that constitutional 
condition ; syphilis in babies may first manifest itself during or after an 
attack of whooping-cough ; and acute tuberculosis is a not unfrequent 
sequel to the disease. Measles and pertussis seem to have a certain 
affinity in that they both produce an especially injurious effect upon 
scrofulous children. In such subjects chronic caseous enlargements of 
the cervical and bronchial glands are common : catarrhal inflammation of 
the lungs tends to pass into a chronic stage and produce serious mischief, 
and chronic bronchitis with emphysema may make the child a permanent 
invalid. Acute tuberculosis, when not the consequence of hereditary 
diathetic tendency excited by the occurrence of whooping-cough, may 
be set up as a result of softening of caseous bronchial glands, and this 
at a considerable interval of time after the primary disease has come to 
an end. 

Besides these constitutional conditions there are other local conse- 
quences of whooping-cough which it is important to be aware of. 

Laryngismus stridulus is sometimes a relic of the disease, the spasm 
persisting although the other symptoms have ceased. This is not com- 
mon, and probably only occurs in the subjects of rickets. 

Children who have lately passed through an attack of whooping-cough 
are often slow to recover their strength and healthy appearance, even 
although they are innocent of any diathetic taint, and have no chest af- 
fection to set up pyrexia and be a cause of weakness. A group of symp- 
toms is often noticed in such subjects which I have elsewhere described 
under the name of " mucous disease," * and which indicates a marked 
degree of impairment of nutrition. The child is languid and pale, or has 
a dingy sallow complexion ; he loses flesh, is easily tired, and sleeps badly 
at night. There is often some discolouration under the eyes, and the 
complexion may turn suddenly ghastly white, as if the child were going to 
faint. Often he does faint ; and he frequently complains of a stitch in the 
side and is subject to flatulent pains about the belly. The tongue pre- 
sents a peculiar appearance. It has a glossy slimy look, is often coated 
with a thin gray fur, and the large papillse at the sides, although not 
prominent, are unusually distinct. A curious irritability is a characteristic 
feature of the disorder. The child is capricious and fretful, and often 
cries without cause. He quarrels needlessly w T ith his brothers and sisters, 
and is sometimes quite a torment in the nursery. At night he dreams and 
often wakes up in violent panic. The "night terrors" of children usu- 
ally occur in the subjects of this derangement, and sometimes the child 
gets out of bed and wanders about in his sleep. These symptoms have no 
regular progression. They are better and worse. Sometimes the child 
seems almost well ; then, in a day or two, he is as bad as ever. The 
patients are subject to what are called "bilious attacks." They are seized 
suddenly with vomiting and purging, which lasts for twenty -four hours or 
a day or two, and at these times get rid of large quantities of thick mucus 
both from the stomach and bowels. After this relief they seem better for 
a time. They are less irritable and languid, their temper improves, and 
their rest at night is no longer disturbed. After a few days, however, the 
symptoms return, and continue until they are again relieved in the same 
way. As a rule, the bowels are rather costive, and an aperient always 
brings away much mucus with the stools. 

These symptoms are due to a continuance of the mucous flux from the 

1 See The Wasting Diseases of Children, 4th ed. 



122 , DISEASE IN CHILDREN. 

alimentary canal which is always present to a greater or less degree in 
cases of pertussis. This copious alkaline secretion acts as a ferment and 
causes an acid change in the more fermentable articles of food. The acid 
thus generated partially coagulates the mucus, so that this forms a thick 
coating round the interior of the digestive tube, and also covers the 
masses of food swallowed. Consequently a proper admixture of food with 
the gastric juices and other digestive fluids is interfered with, digestion is 
slow and imperfect, and of the food which is digested only a small part is 
brought into contact with the absorbent vessels. The child consequently 
gets thinner and paler. He is uneasy on account of flatulent pains from 
gases disengaged in the process of fermentation, and irritable on account 
of the excess of acid with which the system is charged. In bad cases the 
emaciation may be very great, and although the appetite may be large, 
the food taken seems to be, and often actually is, nearly useless for pur- 
poses of nutrition. Commonly, however, when the derangement is severe 
the appetite fails, and great difficulty is found in persuading the child to 
take any nourishment at all. Parasitic worms, which find in the alkaline 
mucus a congenial nidus for development, frequently complicate this de- 
rangement, but it is to the digestive disorder and not to the worms that the 
symptoms are really due. 

Diagnosis. — It is often very difficult to say whether or not a child has 
got whooping-cough. At the beginning of the catarrhal stage a diagnosis 
is impossible. At this early period we can only detect the signs of catarrh, 
and unless the complaint is largely prevalent at the time, or other children 
in the house are suffering from pertussis, there is absolutely nothing to 
make us even suspect its existence. Often, towards the end of this stage, 
the frequency and peculiar violence of the fits of coughing may rouse our 
suspicions, and if a genuine paroxysm occur, doubt, of course, ceases to 
be possible. But although fully developed whooping-cough cannot be mis- 
taken, the modified form of cough which is often all that we can detect 
may be easily misinterpreted. A more or less prolonged cough with a 
faint whoop from slight laryngeal spasm is not very uncommon in a child 
suffering from chest complaint, and an abortive pertussis may sometimes 
give rise to no more characteristic symptoms than these. In making the 
distinction no arguments drawn from the acuteness of the attack or the 
early period at which the cough assumed the spasmodic character can be 
relied upon, for modified pertussis may be as slight and transient as any 
mere pulmonary catarrh. It is of far greater importance to notice that in 
a mild form of whooping-cough the general health is good, and that an 
examination of the chest reveals little deviation from the normal state of 
things ; while a chest affection sufficiently serious to produce an imitation 
of whooping-cough will injure the general health and modify the physical 
signs. It is usually in catarrhal pneumonia that this violent prolonged 
cough is noticed. In such cases we find the symptoms and physical signs 
of this disease, and we exclude pertussis by remarking that the cough did 
not become paroxysmal until the chest disease was well developed. In a 
case of real pertussis with secondary catarrhal pneumonia, the character- 
istic cough is very much modified immediately the complication begins. 
Paroxysms of violent cough with some spasm of the larynx are often no- 
ticed in cases of enlargement of the bronchial glands. But here we get 
other signs of pressure upon the pneumogastric nerve : the breathing is 
more or less oppressed and the voice is thick and hoarse between the 
attacks of cough. Besides, the venous radicles of the face, neck, and chest 
are usually more visible than natural from pressure upon the innominate 



WHOOPING-COUGH— DIAGNOSIS— PROGNOSIS. 123 

vein ; there is no expectoration of ropy mucus ; and the disease is not 
capable of being communicated to other children. 

When convulsions occur in a case of whooping-cough it is very impor- 
tant, with a view to prognosis, to ascertain their mode of origin. If the 
convulsion is symptomatic of the onset of an inflammatory complication, it 
is accompanied by a rise of temperature and followed by a diminution in 
the spasmodic symptoms and a modification of the physical signs in the 
chest. If it announces the occurrence of collapse of the lung, the charac- 
teristic symptoms which mark that lesion w T ill be present. 

If the convulsion arises from exaggeration of the nervous disturbance 
which is one of the peculiarities of the disease, it will have been preceded 
by signs of unusual agitation in former fits of coughing. Such seizures are 
only seen in children known to be nervous, sensitive, and impressionable ; 
they follow immediately upon the cough, and between the attacks no 
signs of nervous disturbance remain. So also in the case of convulsions 
arising from partial asphyxia : the nervous attack is excited by extreme 
violence of spasm, but after the fit has passed off no signs of cerebral 
lesion are left behind. If, after a fit, there is squinting, drowsiness, 
stupor, or other sign of nervous disturbance, we may fear that congestion 
of brain is present or that thrombosis of the cerebral sinuses has occurred, 
and should watch the case with grave apprehension. 

Prognosis. — Whatever be the age of the child, the prognosis is favour- 
able so long as the disease remains uncomplicated ; but if a complication 
arise the prospect is less hopeful, and in a very young child any addition 
to the normal course of the complaint is to be regarded with anxiety. 
Convulsions, bronchitis with collapse, and catarrhal pneumonia are the 
principal causes of an unfavourable issue to the disease. 

In the case of convulsions, if the attack can be connected with nervous 
agitation or the onset of an inflammatory complication, or if, after the fit, 
the child seem bright and well, there is still room for favourable anticipa- 
tion. If, however, the seizure is symptomatic of diffused pulmonary col- 
lapse ; if it occur in the course of an extensive pulmonary inflammation ; 
or if it be followed by drowsiness, squinting, or sign of cerebral lesion, 
there is little prospect of the child's recovery. Sometimes we can antici- 
pate the occurrence of convulsions. If we find the child to be nervous and 
impressionable, and we notice that he displays unusual agitation and ex- 
citement on the approach of the paroxysm, we may be prepared for an 
attack. So also if we find that the face becomes very blue during the 
cough, and that the spasm of the larynx is unusually prolonged, we may 
fear that an eclamptic attack may ensue. Laryngismus stridulus, as it 
supplies an additional obstacle to the aeration of the blood and tends to 
promote collapse of the lung, is an unfavourable sign. If it occur in 
combination with extensive lung mischief, the prospect is a very hope- 
less one. 

If the pulmonary catarrh becomes aggravated, the presence or absence 
of rickets is a very important matter. Softening of ribs is a great obstacle 
to efficient breathing ; and if the presence of thick mucus in the tubes pro- 
vides an additional impediment to the entrance of air, the occurrence of 
collapse is imminent. If, with this, the spasms are violent, and the child 
seem much exhausted at the end of the fit of coughing, collapse of the lung 
may be considered inevitable. In such a case the prognosis is a very 
gloomy one. 

If the catarrh pass to the small air-tubes and vesicles, and set up catar- 
rhal pneumonia, the state of the child is serious. Still, if the patient be 



124 DISEASE IN CHILDEEN-. 

of healthy constitution and the pertussis of comparatively mild type, he 
has a chance of recovery. In a rickety child the prospect is very bad. In 
one of scrofulous constitution, if he cto not succumb immediately, there is 
every likelihood that a chronic consolidation of one or both lungs will be 
left behind. 

Treatment. — The treatment of whooping-cough resolves itself into gen- 
eral measures for preventing complications and furthering the normal 
working of the animal functions ; also, in special treatment for shortening 
the disease and diminishing violence of spasm. 

If possible, the child should be confined to two rooms opening into one 
another, so that he may inhabit them alternately, and get the benefit of effi- 
cient ventilation. Draughts should be avoided, and the temperature be kept 
as nearly as possible at 65° Fahr. If the rooms have no door of communi- 
cation, the child should be taken from one to another, wrapped from head to 
foot in a blanket. Next, quiet and the avoidance of all sources of excite- 
ment and irritation should be enforced. If old enough to be amused, 
quiet games and picture-books may be supplied ; and a teachable child is 
not to be worried with lessons if he is disinclined for them. His dress 
should be suitable to the season, but bare arms and legs must be forbid- 
den, and the chest should be covered with cotton-wadding if the weather 
be changeable or cold. 

In regulating the diet care should be taken not to overload the stom- 
ach. Four small meals are better than three large ones, and attention 
must be paid to the patient's power of digesting fermentable articles of 
food. The mucus flux from the stomach and bowels, which is a prominent 
feature of the complaint, is an active agent in promoting acidity ; and 
starches must be given, therefore, cautiously and in limited quantities. A 
baby does well upon milk and barley-water (equal parts), and Mellin's 
food, with a pinch of bicarbonate of soda to each bottle. He may also 
have the yolk of an egg twice a week, and, if over ten months old, weak veal 
or chicken broth once in the day. After eighteen months the child may 
have minced meat, or fish, milk, eggs, and stale bread, but potatoes and 
farinaceous puddings are to be avoided. Well boiled cauliflower or greens 
may be given if the patient will take them. 

If the natural vomiting does not sufficiently unload the stomach of mu- 
cus, nature may be aided by the occasional administration of an emetic. 
Sulphate of copper, as recommended by Trousseau, is very useful for this 
purpose, and may be given to a child of one year old in doses of half a 
grain every ten minutes until sickness is produced. Also, it is well to re- 
lieve the bowels by an occasional dose of castor-oil. Looseness of the bow- 
els, such as is common in this complaint, is at once arrested in most cases 
by a dose of this useful remedy. 

Of special drugs for shortening the" attack and relieving spasm, so many 
have been recommended that the mere enumeration of them would occupy 
many lines ; but of really serviceable drugs the number is much more lim- 
ited. The treatment I have myself found to be most useful, and now inva- 
riably adopt, is the following : l — Directly any peculiarity in the cough or 
the occurrence of spasm indicates the nature of the complaint, I at once 
begin the administration of sulphate of zinc and atropia. From a large 
experience of this combination I can speak positively as to its power of 
reducing spasm and shortening the disease. I begin with one-sixth of a 
grain of sulphate of zinc and half a drop of the solution of atropine (P. B.) 

1 The quantities recommended are suitable to a child twelve months of age. 



WHOOPING-COUGH — TREATMENT. 125 

in water sweetened with glycerine, each morning* and evening for two days, 
and then three times a day. After a week the quantity of zinc is increased 
to one-fourth, and still later to one-third of a grain. The atropia, how- 
ever, is given in frequently increasing quantities. Children, although they 
vary in their insusceptibility to this drug, can all take it in large doses ; 
and in whooping-cough where there is spasm to be overcome, the remedy 
is of little value unless given in doses sufficiently large to produce some of 
the physiological effects of the alkaloid. Excluding the belladonna rash, 
which is too uncertain in its appearance to be trusted, dilatation of the 
pupil is the earliest symptom that the system is responding to the action 
of the medicine. This sign is separated by a wide interval from the next 
earliest symptom — dryness of the throat. To be of service, the remedy 
should be pushed so as to produce some effect upon the pupil "With this 
object the dose should be increased every two days by a quarter of a drop 
of the atropine solution, watching the effect. In this way, with perfect 
safety, large quantities of the drug may be administered ; and so employed, 
I think no doubt can be entertained as to the value of the treatment and 
its influence in shortening the course of the spasmodic stage and reducing 
the violence of the attacks. If the spasm is exceptionally severe and seems 
to threaten partial asphyxia, it is wise to give in addition a nightly dose of 
bromide of potassium or ammonium (gr. iij.-iv.). There is one precaution 
which it is well to adopt during this stage. The paroxysms are often most 
frequent and severe at night when the child is asleep. The slightest move- 
ment of air across the face, such as is produced by a person walking near 
the cot, will often excite an attack. These night seizures can usually be 
greatly reduced in number by an expedient suggested, I believe, originally 
by Dr. Marshall Hall. It consists in throwing a fine muslin curtain over 
the cot at night-time. The simplest plan is to have a couple of hoops ar- 
ranged at the ends of the cot, like the "tilts" of a wagon, so as to support 
the curtain at a sufficient height. This arrangement, which corresponds 
to the mosquito curtain used in hot climates, does not interfere with a 
free supply of oxygen, while it effectually stops all wandering currents 
of air. So protected, a child will often sleep the night through without 
an attack. 

At the end of the spasmodic stage and during the period of decline 
alum is very beneficial. This remedy, first recommended by Dr. Golding 
Bird in 1845, has a marked influence in checking too copious secretion and 
bringing the disease to a favourable termination. Two or three grains of 
alum may be substituted for the sulphate of zinc in the atropia mixture, 
and given three times in the day. It is at this time, viz., the end of the 
spasmodic stage and during the period of decline, that I have found the 
quinine treatment especially useful. I have little experience of the drug 
at the beginning of an attack. According to Binz, Jansen, and others, 
who, following the suggestion of Letzerich, direct their attacks against the 
organism which has been supposed to cause whooping-cough, quinine 
given at the beginning of the illness suppresses altogether the spasmodic 
element, and converts the disease into a severe but manageable bron- 
chitis. They recommend the comparatively tasteless tannate of quinine, 
given twice a day in doses of a grain and a half for every year of the 
child's life. 

There is no doubt that to be efficient in pertussis quinine should be 
given in full doses. I have given three times a day two grains of the sulphate 
of quinine to children between twelve months and two years old towards 
the end of the spasmodic stage, and have thought that the disease was cut 



126 DISEASE IN CHILDREN. 

short by this means. Another combination which acts sometimes at this 
period of the illness with wonderful promptitude is formed by adding two 
drops of the tincture of cantharides to five drops each of the tincture of 
cinchona and paregoric, and giving this dose three times a day. Tonics 
generally are useful during the stage of decline. The preparations of iron 
are especially valuable. Thirty drops each of the compound decoction of 
aloes and iron wine make a good combination ; iodide of iron is of service, 
and the citrate of iron with an alkali may be resorted to. It is a matter 
of great practical importance in all these cases to avoid the use of syrups 
in sweetening the mixture for the infant's palate. Glycerine, being non- 
fermentable, is far safer ; or we may use a few drops of chloric ether for 
this purpose. 

Many other drugs are used in the treatment of whooping-cough. The 
old treatment by dilute hydrocyanic acid and that by dilute nitric acid, 
each of which has had its day, has now, probably, fallen into complete dis- 
use. Opium, however, in some form has not been completely superseded 
by belladonna. The preparations of morphia are still relied upon by some 
practitioners, and the remedy is no doubt a useful one. It should be 
given in sufficient doses to produce slight drowsiness, and this effect 
should be maintained for several days. For a child of twelve months a 
drop of the morphia solution (P. B.) can be given every four hours. There 
is no doubt that the spasm can be reduced by this means ; but the treat- 
ment is, in my opinion, inferior to that by atropine, and necessitates very 
careful watching of the patient lest the narcotic effect of the remedy be 
carried further than is desired. Chloral may be also employed to reduce 
spasm in doses of gr. ij. every four or six hours. It is sometimes used in 
combination with bromide of potassium, and the effect of both drugs ap- 
pears to be heightened by the association. Croton chloral is a remedy 
greatly relied upon by some practitioners. The dose is one grain for a 
child of twelve months, given every four, six, or eight hours in water 
sweetened with glycerine. 

Besides the above methods of treatment the topical action of drugs 
is largely used in the management of whooping-cough. It is now 
nearly thirty years since Dr. Eben Watson advocated swabbing the 
larynx with a solution of nitrate of silver, twenty grains to the ounce. 
The application was repeated every second day, and the spasm is said 
to have subsided at the end of the week. This heroic remedy is not 
now in vogue. Instead, milder applications sprayed into the throat are 
made use of. A two per cent, solution of salicylic acid used regularly in 
this manner is said to diminish rapidly the number of paroxysms. Dr. 
R. J. Lee is a warm advocate of carbolic acid inhalations, and claims for 
them that they induce a daily decrease in the violence of the cough, and 
promote the disappearance of the symptoms within a period varying from 
a fortnight to three weeks. Dr. Lee prefers long-continued inhalations of 
a diluted vapour, and recommends that the air of the room should be kept 
saturated with a weak solution of carbolic acid. As this acid does not 
evaporate when exposed to the air, special means have to be used for con- 
verting it into vapour. Dr. Lee's "steam draft inhaler," which moistens 
the air as well as medicates it, is a useful and simple apparatus. A solu- 
tion of one part of the acid to thirty of water is to be used for vaporisa- 
tion, and by this means the child may pass a large part of his time in air 
kept saturated with a dilute medicated vapour. If carbolic acid be in- 
haled in the ordinary way from a mouth-piece, the solution should not be 
stronger than one part in eighty parts of water. 



WHOOPING-COUGH — TPwEATMENT. 127 

External applications have not been neglected in the treatment of 
whooping-cough. Many patent remedies, such as Roche's embrocation, 
which is composed of the oils of cloves and amber with double their quan- 
tity of olive-oil, belong to this class. Stimulating liniments are often useful 
if the catarrh of the chest is severe, and if applied along the sides of the 
neck, and to the spine as well as to the chest, may help to reduce the spasm. 
Mustard poultices to the back are favourite remedies with some practi- 
tioners, and it is said that if applied along the whole length of the spine for 
six or eight minutes every night before the child is put to bed a speedy im- 
provement is noticed in the symptoms. 

When complications arise in the course of whooping-cough, special 
measures must be adopted for their relief. If the vomiting of food become 
excessive, so as to interfere seriously with the child's nutrition, it may be 
often relieved by emetics of sulphate of copper (half a grain to the tea- 
spoonful) given every day or on alternate clays, so as to clear away tena- 
cious mucus from the stomach. Chloral is useful in these cases by its 
power of diminishing reflex actioD. Excessive vomiting is usually found 
in cases where the laryngeal spasm is extreme, and the remedies which 
are useful in alleviating this symptom have also a beneficial action in 
checking too forcible contraction of the diaphragm. Looseness of the 
bowels is usually easily controlled by a dose of castor-oil. In this coun- 
try diarrhoea seldom becomes troublesome, but in warm climates during 
the hot season choleraic diarrhoea may supervene. This must be treated 
according to the rules laid down for the management of that serious con- 
dition. 

If laryngismus stridulus complicate the paroxysm, bromide of am- 
monium or potassium (gr. iij.)maybe given with atropia two or three 
times a day ; and the same treatment is useful if unwonted nervous excite- 
ment, or signs of cerebral disturbance, indicate the imminence of a convul- 
sive fit. If the spasm be prolonged and seem to threaten suffocation, slip- 
ping the child's hands into cold water will often relax the glottis at once. 

Convulsions must be treated according to the special condition from 
which they appear to have arisen. In the more serious form of eclamptic 
attack, such as that induced by collapse of lung, catarrhal pneumonia, or 
thrombosis of intracranial sinuses and veins, the treatment must be directed 
against the complication by which the nervous seizure has been excited. 
Convulsions set up by pure nervous agitation, or by partial asphyxia from 
violence of laryngeal spasm, are usually to be controlled by the administra- 
tion of chloral in the quantities already indicated. If the seizures occur in a 
rickety child, and appear to be the consequence of digestive disturbance 
and acidity (a not uncommon case), a dose of ipecacuanha wine, followed 
by an antacid and aromatic mixture, will usually put an end to them at 
once. 

If the pulmonary catarrh become severe and threaten collapse of the 
lung, prompt steps must betaken to ward off this dangerous complication. 
Stimulating applications should be applied to the chest and back ; occa- 
sional emetics should be given to aid in the expulsion of mucus ; and the 
child's strength must be supported by a suitable supply of alcoholic stim- 
ulant. In these cases alcohol should be given boldly. A young child in a 
weakly state from acute disease will respond well to such treatment, and 
a few timely doses of brandy-and-egg, or other powerful stimulant, will 
quickly give him renewed strength to struggle against his disease. It may 
be necessary to give a teaspoonful every hour, or even half hour, imtil the 
difficulty is overcome. 



128 DISEASE IN CHILDREN. 

If catarrhal pneumonia supervene, the complication must be treated 
upon the principles laid down in the chapter relating to that subject. 

When the disease is at an end, change of air to a dry, bracing spot or 
to the sea-side is of importance. Eemembering the frequency of glandular 
enlargements and the danger of tuberculosis, we should recommend such 
measures as are required for restoring impaired nutrition and replacing 
lost strength. Cod-liver oil is very valuable, alcohol is of service, and iron 
is usually indicated. 

The symptoms described as " mucous disease," which are often seen in 
children of three or four years of age or upwards after an attack of whoop- 
ing-cough, are quickly removed by careful regulation of the diet. The 
child should be fed upon meat, eggs, fish, poultry, and milk ; and potatoes, 
farinaceous puddings, fruit, cakes, sweets — all articles, in fact, capable of 
affording material for fermentation must be strictly forbidden. A mild 
aperient, such as the compound liquorice powder, should be given twice a 
week to ensure the expulsion of excess of mucus from the bowels ; and 
iron with alkalies, or iron wine with compound decoction of aloes (aa 3 ij. 
for a child of five years of age), should be given two or three times a day, 
two hours after meals. 



art % 
iSE NOT INFECTIOUS 



CHAPTER I. 

RICKETS. 



Of all the chronic diseases to which young children are liable, none sur- 
passes in interest and importance the one now to be considered. The fre- 
quency with which rickets occurs, the variety of tissues it affects, the influ- 
ence it exercises upon the course and termination of intercurrent maladies, 
and the distressing and often fatal consequences which its presence involves 
render this disease especially deserving of careful study. 

Although dissimilar in many respects from the class of so-called dia- 
thetic diseases, viz., those which arise as a consequence of a distinct con- 
stitutional predisposition, rickets is yet a general affection, for it impairs 
the nutrition of the whole body. Under its influence growth and develop- 
ment are arrested, dentition is retarded, the bones soften and become 
deformed, the muscles and ligaments waste, and in fatal cases alterations 
are often noticed in the brain, liver, spleen, and lymphatic glands. The 
disease usually begins in infancy. It is rare under the age of six months, 
for it seems very doubtful if the cases of so-called congenital rickets are 
true examples of the disease. At the eighth month, however, it begins to 
be common, and from that age until the eighteenth month may be readily 
set up under the influence of causes which interfere with digestion and im- 
pede the assimilation of food. It is less common for the disease to develop 
in children who have been in good health up to the age of eighteen months, 
but it may occur at any time between that age and the seventh year, or 
even in still older subjects. Although beginning at a very early age, the 
disease often continues for several years, and may be seen existing in a 
marked degree in children three or four years old. 

Causation. —Rickets is the direct consequence of mal-nutrition in early 
life. Its causes must therefore be looked for in all the diverse agencies 
which impair the nutrition of the growing frame. The most important of 
these are, no doubt, faults of feeding and hygiene. Insufficient or unsuit- 
able food stints the body of necessary nourishment, and an inadequate 
supply of fresh air renders assimilation defective and weakens digestive 
power. These two causes are most commonly found united in the poorer 
quarters of large cities. An infant who lives amongst other children in 



130 DISEASE IN CHILDEEN. 

one small room, where it breathes a tainted air and derives its only nour- 
ishment from the watery breast-milk of a weakly mother, with the addi- 
tion, perhaps, of a little gruel or sopped bread to quiet it when it cries, can 
only escape rickets by becoming tubercular. By such means an extreme de- 
gree of the malady will probably be produced. But similar agencies, al- 
though operating in a milder form, will produce rickets in any condition 
of life. It is not uncommon to meet with examples of the disease in well- 
to-do families where the child has been kept in-doors for fear of his catch- 
ing cold, and has been supplied with farinaceous compounds largely beyond 
his powers of digestion. Over-feeding with starchy foods is a fruitful 
cause of rickets. The giving of farinaceous matters in excess, or at a time 
when the glandular secretions are insufficient for its digestion, is the com- 
monest fault committed in the hand-feeding of infants. Dr. Buchanan 
Baxter, who tabulated one hundred and twenty consecutive cases of 
rickets, found that in many of them the disease dated from the time when 
farinaceous food w x as first given. It is probable that in these cases the oc- 
currence of mal-nutrition and subsequent rickets is due not so much to 
the excess of starch as to the absence of the more nutritious food for 
which the starch has been substituted. Rickety children so fed are often 
fat, and do not, to the inexperienced eye, convey the impression of being 
under-nourished. Examination, however, discovers that they are by no 
means strong in proportion to their size. Although stout they are weak, 
often excessively feeble ; and it is evident that the plumpness of the child 
is due to disproportionate development of the subcutaneous fat. This 
tissue has been enormously over-nourished while the rest of the body has 
been stinted and starved. 

The time of weaning is often a starting-point for rickets, for the breast- 
milk is usually replaced by some preparation of starch. So also long- 
continued suckling may induce the disease, for the breast-milk after a 
time ceases to satisfy the infant's wants, and too little additional nourish- 
ment is supplied. Therefore whether the food given be insufficient in 
amount or indigestible in form the effect is the same : the child is starved 
and rickets becomes developed. 

In cases where the child lives in a good bracing air the effects of an un- 
suitable dietary are less painfully evident. In dry country places, where 
the infant spends much of his time out of doors, rickets is a more uncom- 
mon disease than it is in localities where the conditions are less favourable 
to health. Want of sunlight, want of cleanliness, and a combination of 
cold and damp are other determining causes which are not without their 
influence in the production of rickets. All these causes must no doubt act 
with especial energy in the case of infants who are naturally weakly, or 
whose strength has been already reduced by some exhausting disease. 
There are, therefore, many conditions which predispose to the complaint. 
Feebleness of constitution on the part of the parents will, no doubt, have 
an influence in this respect, for weakly parents are not likely to beget con- 
stitutionally healthy children. Moreover, a weakly mother is usually unable 
to nurse her baby ; and hand-feeding, unless conducted with extreme care 
and discretion, is often unsatisfactory. A verv large proportion of rickety 
infants are bottle-fed. 

Hereditary tendency is considered by some observers to be an element 
in the etiology of the disease. In the case of so common an affection it 
must no doubt often happen that the father or mother of the patient has 
been previously affected in a similar way ; but that a parent who had been 
rickety in childhood should give birth to a weakly infant, and that this in- 



EICKETS — CAUSATION. 131 

fant, brought up in violation of all the rules of health, should develope 
rickets, is surely but slender evidence in favour of the hereditary trans- 
mission of the disease. Supporters of this theory usually point to the 
cases of so-called " congenital rickets " as instances of the inherited form 
of the disease ; but, as is hereafter explained, there are reasons for exclud- 
ing these cases from the class of true rickets. 

The relation which exists between rickets and congenital syphilis has 
within the last few years been brought into great prominence. M. Parrot 
has laboured to show that rickets is always the consequence of an heredi- 
tary syphilitic taint. The arguments of this observer in favour of his view 
are derived chiefly from morbid anatomy. He points in particular to the 
anatomical changes observable in the epiphyseal ends of the long bones in 
the two diseases as evidence of the specific nature of rickets. But the latter 
is not only a disease of the bones ; and although the epiphyses in the two 
cases may present a certain similarity of lesion, there are other alterations of 
structure in rickets which are different from those of syphilis. Moreover, 
the general symptoms, especially the peculiar tendency to functional ner- 
vous disorders, have no counterpart in the specific disease. Again, rickets 
is constantly met with in cases where the most careful inquiry and most 
minute examination fail to detect any history of venereal taint in the 
parents or sign of it in their offspring. The disease is common in localities 
where congenital syphilis is rare, and rare in places where the latter is 
common. It is met with in animals as well as the human subject, and is 
produced in them by faulty hygiene and bad feeding as it is in the child. 
But it is needless to multiply arguments against the untenable hypothesis 
advanced by this distinguished pathologist. 

Still, although it cannot be allowed that rickets is caused by syphilis, 
syphilitic infants may become rickety ; and it is probable that a parent 
weakened by a former syphilis may, without transmitting the taint to his 
offspring, beget a child of feeble constitution in whom rickets can be easily 
induced. But in both these cases injudicious feeding and insanitary con- 
ditions must come into operation before the disease can occur. 

A pronounced tubercular disposition appears to have a protective power 
against rickets ; for although weakly, phthisical parents may give birth to 
feeble infants who readily fall victims to rickets, it is rare to find the lat- 
ter disease in a family where other members have died of tubercular men- 
ingitis or other form of pure tuberculosis — unless, indeed, the tubercular 
mischief has occurred secondarily to rickets. The reason of this immunity 
seems to be that the causes which are capable of setting up rickets will in- 
duce tuberculosis in a child predisposed to this form of illness and very 
quickly bring his life to a close. 

How it is that these causes give rise to rickets is still undecided. It 
has been shown by the experiments of Friedleben that a diet deficient in 
phosphoric acid and the lime salts is not capable, as was at one time sup- 
posed, of inducing rickets ; indeed, it seems probable that the essence of 
the process is not a mere deficiency of lime in the bones, but an irritation 
of the bone-making tissue. It is asserted by Heitzman that lactic acid ex- 
ercises an irritating influence upon the osteoplastic tissue, and that it is 
this influence, combined with a deficiency in lime salts, which induces the 
disease. There is little doubt that lactic acid is abundantly generated in 
the deranged digestive organs of rickety children, for this acid has been 
detected in their urine. If Heitzman's theory be correct, the acid excites 
irritation in the osteoplastic tissue, and at the same time dissolves and 
helps to eliminate the calcareous matter deposited in the bones. If, in ad- 



132 DISEASE IN CHILDREN. 

dition, the supply of lime salts be actually reduced, rickets is set up with 
still greater certainty. 

Morbid Anatomy. — In looking at a case of well-marked rickets the eye 
is at once arrested by the enlargement of the epiphyseal ends of the long 
bones and the deformities of the skeleton which result from softening of 
the osseous framework. In rickets the bones are affected in three ways. 
Growth, although not completely arrested, is retarded and rendered 
irregular ; ossification of parts still remaining cartilaginous is interfered 
with, and bone already ossified is softened. When a longitudinal section 
is made of one of the long bones the whole structure appears deeply red- 
dened from intense congestion. The epiphysis is very large, and the in- 
crease in size is due chiefly to an enormous development of the cartilage, 
which is preparing for the reception of the calcareous salts. The layer of 
cartilage into which the new bone is advancing is called the zone of calcifi- 
cation. That next in order, in which the corpuscular elements arrange 
themselves in vertical columns in preparation for the approach of the 
earthy deposit, is called the zone of proliferation. These two zones are 
greatly thickened and are not separated, as would be the case in the bone 
of a healthy child, by a well-defined straight line of demarcation. In the 
rickety epiphysis the new bony tissue, instead of advancing by regular 
steps into the zone of calcification, no one point being in advance of an- 
other, shoots up irregularly, so that lines or little islets of calcification are 
seen far up in the proliferating zone, while on the other hand specks and 
streaks of uncalcified cartilage are left far below the line of earthy deposit 
completely surrounded by bone. Moreover, medullary spaces are formed 
in unusual places, and appear even in the proliferating zone of cartilage 
far in advance of the margin of ossification. The cartilage cells become 
the seat of calcareous impregnation, 1 and are in many cases converted into 
bone corpuscles. Small isolated masses of lime can also often be seen 
scattered through the matrix — enough in many cases to give a dotted ap- 
pearance to a section of the cartilage. 

Changes similar to those described in the epiphyses take place at the 
surface of the shaft of the long bones and in the flat bones. The perios- 
teum becomes excessively thick and very vascular, and is connected so 
firmly with the bone beneath that it cannot be detached without fragments 
of the latter being stripped away with it. Its connective-tissue corpuscles 
undergo rapid proliferation and become transformed directly into bone 
corpuscles. The calcifying process is irregular here as it is in the epi- 
ph} r ses, so that layers of firm bony tissue are interspersed with others 
composed of a fibrous matrix containing connective tissue or bone cor- 
puscles and medullary spaces. In the flat bones, especially those of the 
skull, the irregularity with which calcareous matter is deposited is well 
seen. The new porous bone occupies chiefly the surface and edges. In 
the cranial bones a special change is often found. In certain spots the 
bone becomes excessively thin and transparent (cranio-tabes). This con- 
dition is due to deficient deposit of lime salts in the external layers and 
absorption of the soft tissue in places, here and there, from the pressure of 
the brain. 

Bones in which ossification is thus delayed and perverted are usually 
soft. The softening is the consequence of the smaller proportion of earthy 

1 It lias been doubted whether this change occurs in healthy ossification, for in the 
normal process the calcification of the intercellular matrix which surrounds the carti- 
lage cells conceals the latter from view. In rickety bone the calcifying granules are 
deposited first in the cells, so that the changes in them can be distinctly seen. 



RICKETS— MORBID ANATOMY. 133 

salts they contain and the larger percentage of organic matter. But the 
deficiency of lime salts is due not to their removal after deposition, but to 
the sluggishness with which they are deposited. The corpuscular elements 
of the periosteum are proliferated in large quantities, and the new matter 
is but slowly and imperfectly converted into bone. The circumference of 
the shaft, therefore, consists in great measure of spongy lamellse which are 
only partially ossified. All this time in the interior of the bone the normal 
enlargement of the medullary canal by absorption still continues, so that 
as long as the rickety process is active the proportion of properly con- 
structed osseous matter containing its due percentage of earthy salts is 
continually diminishing. Such a bone must necessarily be. yielding and 
subject to ready distortion. This, however, is not the only cause of the 
bone deformities. According to Strelzoff, the osseous trabecule have an 
abnormal arrangement in rickety bone. They are disposed radially in- 
stead of concentrically. He maintains that this irregularity further di- 
minishes their power of resistance to external pressure and is an additional 
source of weakness. 

At the height of the disease the bones, besides being softer, are speci- 
fically lighter than natural, and contain an undue proportion of fatty 
matter. Moreover, the cartilage contains a high percentage of water. 
The bone on analysis has been shown to consist of 33 to 52 per cent, of 
earthy salts, instead of 63 to 65 as in health, and its animal matter is said 
to yield no gelatine on boiling. 

When the disease becomes arrested, ossification in the soft, newly 
formed tissue takes place rapidly. The loose spongy structure closes up 
and becomes thick and hard, and the whole bone is heavy and dense. 

The morbid changes in the osseous system form, no doubt, the most 
characteristic feature of the rickety state : but rickets is not merely a dis- 
ease of the bones. In addition, various pathological changes are discovered 
in the bodies of children who have died while suffering from this affection. 
In some the liver, spleen, and lymphatic glands are found diseased, the 
muscular structure is altered in bad cases, the brain may be affected, and 
the urine almost invariably exhibits pathological characters. 

The alterations in the liver, spleen, and lymphatic glands are by no 
means present in every case, or even in every marked case of the disease. 
The affected organs are enlarged, tough, and solid to the touch, and heavy 
out of proportion to their size. The change is usually most marked in the 
spleen. Dr. Dickinson considers it to be due to no "new growth or infil- 
trated deposit," but to a hyperplasia of the normal tissue of the organ, and 
chiefly of the interstitial connective tissue. The fibrous and epithelial ele- 
ments are hypertrophied, and at the same time their earthy salts are de- 
ficient in quantity. In the liver the fibroid sheath within the smaller portal 
canals is twice its natural size, and in the glandular structure the yellowish 
acini are bounded by a thin pinkish or grayish line. In the spleen the in- 
terstitial connective tissue may become so hypertrophied that the trabecule 
are as thick as the spaces they enclose. In the meshes the corpuscles are 
seen by the microscope to be crowded together. The organ is hard and 
resistant, so that it can be cut with the utmost ease into thin sections. Its 
surface is deep red or purple in colour, with smooth white spots from en- 
larged Malpighian corpuscles. Its section is deep red mottled with pale 
buff colour. But little blood can be squeezed from the cut surface. The 
lymphatic glands are sometimes also enlarged and hard. They are white 
and opaque on section from accumulation of their cellular contents. 

Enlargement of the liver in rickets is not always the consequence of the 



134 DISEASE IN CHILDEEN". 

pathological condition described. If a rickety child be much wasted from 
intestinal catarrh or other digestive trouble, the liver may be swollen from 
fatty infiltration. If he have been subject to repeated pulmonary catarrhs 
with great interference with the respiratory function, the organ may be 
enlarged from chronic congestion. So also turgescence of the spleen may 
be found unaccompanied by any appreciable lesion of the liver or lymphatic 
glands. In some cases the increase in size of the organ appears to be due, 
as in the case of the liver, to a chronic congestive process which causes a 
large development of hyaline fibroid material. In others the spleen seems 
to be the seat merely of simple hyperplasia and presents the ordinary 
characters of hypertrophy, such as are seen in some cases of inherited syph- 
ilis and in the ague cachexia. This form of enlargement is referred to 
elsewhere (see page 238). 

The muscles have been noticed by Sir William Jenner to be small, pale, 
flabby, and soft. Their fibres under the microscope are softer and paler 
than natural, with the strise very indistinctly marked. The brain is some- 
times small and shrunken, so that fluid is thrown out to fill up the space 
left vacant in the skull cavity. It is also sometimes enlarged, so much so, 
in some cases, as to cause distention of the cranium. Dr. Hilton Fagge has 
referred to a case which was taken to be one of advanced hydrocephalus 
until an examination of the body after death showed that the brain filled 
up the cranial cavity completely. In such cases the organ, although en- 
larged, has a healthy appearance and is of natural consistence. The hyper- 
trophy is said to be in the neuroglia without any increase in the nerve- 
elements. 

The urine contains an increased proportion of phosphate of lime, and 
lactic acid has been found in it by some observers. The secretion is pale 
in colour and often deposits crystals of oxalate of lime. Often, also, as is 
so commonly the case in children in whom acid is largely generated from 
fermentation of food, crystals of uric acid and even considerable quantities 
of red sand may be passed from the kidneys. 

In addition to the above pathological conditions, which may be con- 
sidered to arise directly from the general disease, there are others which 
may be looked upon as accidental since they are induced mechanically by 
the deformities of the thorax resulting from the softening of the ribs. In 
all cases of distortion of the framework of the chest two pulmonary lesions 
are invariably present. These are emphysema and collapse. The emphy- 
sema is seated at the anterior borders of the lungs, and extends backwards 
for about three-quarters of an inch from their free margins. Immediately 
outside this line of dilated lung tissue is a line of collapse which separates 
it from the healthy pulmonary substance beyond. These lesions occur to- 
gether and, although not dependent one upon another, are produced by 
the same mechanical means. During the act of inspiration the softened 
ribs sink in, and the pressure of the enlarged ends of the ribs compresses 
the lung tissue with which they are in contact so as to prevent its expan- 
sion by the air which inflates the remainder of the lung. While, however, 
the diameter of the chest is narrowed laterally, its antero-posterior diameter 
is increased by the protrusion of the sternum. Consequently the alveoli 
of the anterior borders, immediately behind the breast-bone, are dis- 
tended by the air which is forced into this part to fill up the resulting 
space. 

Pulmonary collapse is not always limited to the parts of the lung cor- 
responding to the ends of the ribs. There is often to be seen, in addition, 
a certain amount of atelectasis at the bases of the lungs behind. Collapse 



RICKETS — MORBID ANATOMY. 135 

at this part of the lung is due to pulmonary catarrh and plugging of an 
air-tube with mucus. Its mechanism is described elsewhere (see p. 465). 

The enlarged epiphyses of the ribs, besides their effect upon the lung- 
tissue, are also the cause of the patches of circumscribed opacity seen on 
the visceral surface of the pericardium and on the spleen. That on the 
pericardium is situated on the left ventricle a little above the apex of the 
heart. At this point the heart at each beat comes into contact with 
the nodule of the fifth rib. That on the spleen is produced in the same 
way by attrition, the organ as it rises and falls in respiration being- 
rubbed against a similar costal projection. In each case the white patch is 
limited to the fibrous layer. 

From a consideration of the morbid changes discovered in the bodies 
of rickety children, it is evident that the disease is a very special one, in- 
volving very wide-spread lesions of structure. Attention has lately been 
directed to the whole subject of bone changes in the young subject, and 
it is asserted that many cases in which bone softening has been pronounced 
are not real examples of rickets, but ought rather to fall under the head- 
ing of osteo-malacia ; the osseous changes resembling closely those observ- 
able in cases of osteo-malacia in the adult. The question is of importance, 
for the pathology of the two conditions is essentially dissimilar. In osteo- 
malacia softening is the consequence of a removal of the earthy constitu- 
ents from perfectly formed bone. In rickets ossification is incomplete, 
and much new material is thrown out which undergoes very imperfect 
calcification. The question can only be decided by a careful study of the 
morbid appearances. In the case of a rickety little girl, aged eighteen 
months, described by Dr. Kehn of Frankfort, there was marked distortion 
and softening of many of the long bones, with other signs usually consid- 
ered characteristic of rickets. The disease, however, was judged to be 
osteo-malacia on the ground that although softening was a marked feature 
in the bones, the epiphyseal ends were only moderately swollen, and in 
the bones of the lower extremities were hardly swollen at all. Moreover, 
the whole skeleton was excessively thin and the lower extremities were 
quite straight. There was, however, a considerable formation of soft peri- 
osteal deposit ; and a rickety element in the case was admitted. It is pos- 
sible that true osteo-malacia may be grafted on a case of rickets, as is 
supposed by Dr. Eehn to have happened in the instance referred to, but 
further observations are to be desired before any definite conclusion in 
the matter can be arrived at. 

Before closing the subject of the pathology of rickets a few words may 
be said with regard to the cases of so-called " congenital rickets." This 
term is applied to a condition in which the limbs of a new-born child are 
found to present peculiar characters. The shafts of the bones are short 
and thickened, and may be found bent or even broken. At the same time 
the epiphyses are swollen, soft, and quite cartilaginous. The condition, 
however, differs materially from true rickets, and has been compared by 
Eberth to that found in cretinous children. In all recorded cases where 
the post-mortem appearances have been noted the shafts of the bones 
have been found much ossified and remarkably thick and stunted. This 
peculiarity gives, of course, a curious shortness to the limbs. ' The dia- 
physes, instead of being imperfectly ossified as in rickets, with great 
jDorosity of the medullary parts of the bone and thickness of the perios- 

1 In a case described by Dr. Barlow the upper limbs reached only to the umbili- 
cus, and the lower extremities measured no more than five inches in length. 



136 DISEASE IN CHILDREN. 

teum, are excessively hard and compact. Fibrous tissue derived from the 
inferior layers of the periosteum intrudes between the epiphysis and the 
shaft. The epiphyses, also, are enlarged generally and not only at the line 
of calcification, as in rickets ; and their microscopical characters present 
sensible differences. In a case recorded by Urtel the cartilage cells in the 
epiphyses were found lying confusedly together. As they approached the 
diaphysis they were seen to become flatter, especially in the peripheral 
portions, and finally passed into the layer of connective tissue which sep- 
arated the greater part of the epiphysis from the shaft of the bone. The 
resemblance between these cases and cretinism is displayed not only by 
the stunting and firm ossification of the diaphyses. There is the same 
tendency to early union by ossification of the basi-occipital and post- 
sphenoidal bones. Some specimens of " congenital rickets " preserved in 
the Museum of the Royal College of Surgeons exhibit this peculiarity, 
and in others, where the soft parts remain intact, many of the facial char- 
acteristics of the cretin are also to be observed. 

Symptoms. — As might be expected in a disease which arises as a direct 
consequence of faulty nutrition, the symptoms proper to rickets are usu- 
ally preceded by others indicating a general interference with the nutritive 
processes. Digestive derangements are common, but these comparatively 
seldom consist in attacks of severe or repeated vomiting or diarrhoea. In 
most cases the derangement is limited to a lessening of digestive power, so 
that the motions, without being actually loose, are more frequent than 
natural. They are large, pasty-looking, and offensive from the quantity of 
farinaceous and curdy matters which are passing undigested out of the 
body. At this time the child is often irritable and fretful. His belly may 
be swollen from flatulent distention, and he frequently cries with pains 
in the abdomen. For this reason he may be often found asleep in his cot 
resting on his chest, or supported on his knees and elbows with his head 
buried in the pillow. The urine is often very acid and causes uneasiness 
in micturition. If the child perspires copiously the renal secretion may 
contain considerable quantities of uric acid sand. 

Unless by judicious treatment and diet the alimentary canal be restored 
to a healthy state the child, although often still plump to the eye, becomes 
pale and flabby. Then, after an interval which varies in duration according 
to the natural strength of the patient and the more or less wholesomeness 
of his surroundings, the early symptoms are noticed. The onset of the 
disease is announced by three special symptoms. The child begins to 
sweat about the head and neck ; he throws off his coverings at night and 
lies naked in his cot ; and begins shortly afterwards to exhibit uneasiness 
if much danced about in his nurse's arms or handled without the utmost 
gentleness. 

The sweating is profuse and occurs principally during sleep. At night 
beads of moisture may be seen standing on his brows, and the sweat 
tricklesoff his head on to the pillow, which is often saturated by the secre- 
tion. If the child fall asleep in the day-time, or even if he exert himself 
much while awake, the same phenomenon may be noticed. The irritation 
of this perspiration often gives rise to a crop of miliaria about the neck, 
behind the ears, and on the forehead. The superficial veins of the temples 
are full, the jugular veins are unusually visible, and the carotid arteries 
may be felt to pulsate strongly. 

The desire of the child to lie cool at night comes on almost at the same 
time with the preceding, and may be observed in the coldest weather. It 
is, indeed, a frequent cause of catarrh in these patients, and I have seen 



EICKETS— SYMPTOMS. 137 

many cases in which continued looseness of the bowels was apparently 
maintained by repeated chills so contracted. For the same reason a fre- 
quent cough from pulmonary catarrh is a common symptom. 

General tenderness usually begins to be noticed at a certain interval 
after the two other symptoms which have been mentioned. It is shown by 
unusual sensitiveness to even slight pressure, and appears to be seated in 
the muscles as well as the bones. The child cries if lifted up at all 
abruptly or subjected to any jolt or jar, and prefers to he quietly in his 
cot or on the lap of his nurse. This symptom seldom occurs until the 
osseous changes are well marked. It is accompanied by uneasiness or 
pain about the head, which is indicated by a monotonous movement of the 
head from side to side upon the pillow. The hair covering the occiput is 
often worn away by this constant movement, and the bareness of the back 
of the scalp from this cause is a very characteristic symptom. Tenderness 
is not always noticed. It is usually confined to cases where the disease is 
severe. In the mild cases, which are shown merely by a slight enlarge- 
ment of the wrists and ankles, without any apparent softening of the bones, 
the symptom is usually absent. 

The bone changes consist in an enlargement of the epiphyseal ends of 
the long bones, in a thickening of the flat bones, and in a general softening 
of all. The enlargement of the ends of the bones occupies the point of 
junction of the shaft with the epiphysis. Both extremities of the bone may 
suffer, but the change is naturally most obvious in the part which is near- 
est to the surface. The ribs at their sternal ends are usually the first to be 
affected ; then the bones of the wrists. As a rule, the epiphyseal swelling 
is more marked in the bones of the upper extremities than it is in those 
of the lower. The thickening of the flat bones is well seen in the bones of 
the cranium, and the softening of all the bones is one of the causes of the 
deformities of the trunk and limbs which are so common in early life. It 
must not, however, be supposed that every case of rickets ends in softening 
and distortion. All degrees of severity of the disease may be met with, 
and in mild cases softening and the consequent deformities of bone are 
entirely absent. Even in more severe cases we must not expect in every 
instance to find all the symptoms to be enumerated. In one child the 
epiphyseal swellings attract most attention ; in another the softening of 
the bones. In some the chest is excessively distorted and the bones 
of the limbs are comparatively straight. In others the limbs are greatly 
twisted while the thorax is but little altered from the normal shape. These 
differences are said by Baginsky to be determined by the part of the 
skeleton in which growth happens to be most active at the time of the 
attack. 

In a pronounced case of rickets the effect of the bone lesions is very 
striking and peculiar : 

The skull is large with a long antero-posterior diameter, and often, on 
account of the comparatively small size of the face, looks larger than it 
really is. The forehead is square from exaggeration of the bosses of the 
frontal bones, and is sometimes very prominent from the development in 
the bone of cellular cavities. The fontanelle is large and remains open 
long after the end of the second year. Sometimes, if the size of the brain 
is increased, or there is excess of fluid in the skull cavity, the sutures in 
connection with the fontanelle can be felt to be more or less distinctly 
gaping. On account of the thickening of the edges of the flat bones the 
margins of the sutures and fontanelle are elevated, so that the latter feel 
depressed and the sutures are indicated by furrows. The posterior fon- 



138 DISEASE IN CHILDREN. 

tanelle has usually disappeared before the beginning of the illness, but in 
extreme cases, where the disease began early and the symptoms are pro- 
nounced, it may be felt to be still unclosed. 

In every case of rickets the condition known as " cranio-tabes " and 
described by Els'asser should be searched for. It is best detected by 
pressing gently with the tips of the fingers on the posterior surface of the 
head. If cranio-tabes be present, spots will be felt where the bone is thin, 
soft, and elastic, as if at this point it had been converted into tightly 
stretched parchment. The spots are seldom larger than the diameter of a 
good-sized pea, and are usually confined to the occipital bone. They are 
caused by absorption of the imperfectly ossified bone from its compression 
between the pillow and the brain as the child lies in his cot. They may 
be met with as soon as the third month of life, and are said to be the ear- 
liest sign of the disease. 

A rickety child's hair is usually thin, and is often kept moist by the 
copious perspirations to which the head is subject whenever the patient 
falls asleep. In most rickety children a systolic murmur of variable inten- 
sity can be heard with the stethoscope applied over the fontanelle. Ac- 
cording to Senator, the symptom merely shows that an ossified membrane 
is better fitted than the cranial bones to transmit to the ear sounds gener- 
ated in the cerebral vessels. There is no doubt that it is rarely heard in 
children in whom the fontanelle has closed. The murmur is sometimes 
curiously loud. Not long ago a pallid, flabby little girl, between two and 
three years old, the subject of rickets, was brought to me from the coun- 
try on account of a strange noise which was heard at times to proceed 
from her head. The child had cut all her teeth, but was very weak on her 
legs. She was subject to attacks of stridulous laryngitis. The fontanelle 
was not quite closed. Her heart and lungs were healthy. It was said 
that in this child a noise like " the purring of a kitten," not continuous, 
but distinctly intermittent, "like a pulsation," could be heard at times. It 
was loudest at the right side of the head. It was not especially loud after 
exertion, and was only occasionally audible. It was heard best immedi- 
ately the child awoke in the morning, and was then distinctly perceptible 
several yards from her cot. During the child's visit to me no cerebral or 
other murmur could be heard with the stethoscope. Still, I had no reason 
to doubt the good faith of the relatives. The mother, who gave me the 
account, told her tale in a straightforward manner, with the air of one who 
was eager to receive an explanation of a mystery which had puzzled her 
and made her anxious. 

The chief cause of the smallness of the face is the imperfect develop- 
ment of the jaws. Fleischmann has drawn attention to the angularity, and 
flatness anteriorly, of the lower jaw. It has lost its normal curve. The in- 
cisors are quite in a straight line ; then at the situation of the eye-teeth the 
jaw forms a sharp angle and bends abruptly backwards. This is due to 
imperfect growth of the middle portion of the jaw. Baginsky describes in 
addition an occasional want of symmetry between the two halves of the 
bone, which gives the appearance of one side being higher than the other. 
The effect of this delayed development of the jaw upon dentition is very 
important. Eickety children are late in teething. At whatever age be- 
fore the completion of dentition the disease may begin, directly the cranial 
or facial bones become affected there is complete arrest in dental develop- 
ment. Thus, if the disease occurs before any teeth have been cut, their 
appearance may be indefinitely delayed. If several teeth have already 
pierced the gum the process stops there, and months may elapse before 



PICKETS — SYMPTOMS. 139 

others are seen. When, however, the teeth do come they are usually cut 
without much trouble ; but they are in most cases of bad quality from im- 
perfect development of the dental enamel, and quickly blacken and decay. 

The chest is deformed in a very characteristic manner on account of the 
inability of the softened ribs to resist the pressure of the atmosphere. 
Under normal conditions, when the ribs rise and the chest expands in the 
act of inspiration, the solid framework of the thorax is able to withstand 
the pressure of the expired air, and the chest easily enlarges to allow of 
inflation of the lungs. Air rushes through the wind-pipe to dilate the 
pulmonary tissue in proportion as the chest-walls expand. In the rickety 
chest, on the contrary, the ribs are not firm but yielding. Consequently 
the framework of the thorax is not rigid enough to resist the pres- 
sure of the air from without, and when the effort is made to expand the 
chest the softened ribs are forced in at the sides — the parts where they 
are least supported. This sinking in of the ribs throws the sternum for- 
wards. AVe therefore find the chest grooved laterally and the breast-bone 
prominent and sharp. The groove is broad and shallow, and reaches from 
the second or third rib to the hypochondrium. The bottom of the depres- 
sion is formed by the ribs outside their junction with the cartilages. 
Therefore along the inner side of the groove the swollen ends of the ribs 
can be seen, looking like a row of large beads under the skin. The groove 
is deepest in children who have suffered much from pulmonary catarrh. 
In such subjects the impediment to the entrance of air, already existing, 
is increased by the narrowing in the calibre of the smaller tubes induced 
by the derangement ; and the softened ribs receive still less support from 
the lung tissue beneath them. In a chest so deformed each inspiration 
increases the depth of the lateral groove, and at the same time produces a 
deep furrow which passes horizontally across the chest at the level of the 
epigastrium. This furrowing of the surface has been shown by Sir Wil- 
liam Jenner to be due not to the traction of the diaphragm, as was taught- 
by Kokitansky, but like the lateral grooves of the chest to atmospheric 
pressure. The liver, stomach, and spleen support the parietes under 
which they he, and prevent the wall at these points from faUing in. 

The spine is often bent. In an infant the cervical curve is increased 
so that the head is supported with difficulty and falls backwards upon the 
shoulders, producing a very characteristic attitude. Also, the weight of 
the head and shoulders, as the child sits bending forwards, causes a pro- 
jection backwards of the dorsal and lumbar spines, which is sometimes so 
sharp as to give the appearance of vertebral caries. The deformity, how- 
ever, subsides completely when the child is taken up under the arms and 
the spine is drawn upon by the weight of the limbs and pelvis. If the pa- 
tient is able to walk, there is an increase in the lumbar and dorsal curves. 
The curvature may be lateral. If the child is carried habitually on his 
nurse's left arm, the trunk sways over to the right ; if. on the right arm, 
the body leans to the left. In all these cases the deformity is due to weak- 
ness of the ligaments and muscles. 

The bones forming the pelvis may be also deformed, and sometimes, 
like the chest, are greatly distorted. The shape assumed by this frame- 
work is very various, for as it is due in all cases to compression of the 
yielding bones, it will be determined partly by the age at which the dis- 
ease begins, and the degree to which ossification has advanced. It is 
therefore different, according to the usual attitude of the child, and to the 
circumstance of his being able or not to walk about. Its most ordinary 
shape is an irregular triangle. Distortion of the pelvis is of great impor- 



140 DISEASE IN CHILDREN-. 

tance in its influence upon child-bearing in the adult female ; but even in 
early life it may have grave consequences. The operation of lithotomy in 
the young subject has been attended with serious difficulties, and even 
been followed by fatal results, on account of this deformity. 

In the bones of the limbs the articular ends are nodular from en- 
largement, but the shafts themselves have often an unnatural shape. In 
the arm the humerus is often curved at the insertion of the deltoid muscle 
by the weight of the forearm and hand when the arm is raised. The ra- 
dius and ulna are curved outwards and twisted, for a rickety child often 
rests his hands on the bed or floor to assist his feeble spine in supporting 
the weight of his trunk. In the femur the head of the bone may be bent 
at an angle with the shaft. The body of the bone is curved forwards if 
the child cannot walk ; for as he sits on his mother's "lap the weight of the 
leg drags upon the lower part of the thigh. If he can walk, the curve is 
an exaggeration of the natural curve — forwards and outwards. The tibia 
is curved outwards if the child is unable to walk, so that when the patient 
is held upright the knees are widely apart. The deformity is due in this 
case to the position commonly assumed by the infant, who is addicted to 
sitting cross-legged on his bed, so as to make pressure upon the outside of 
his ankle. In children who can walk an abrupt curve, having its convexity 
forwards and outwards, is seen in the lower third of the bone. The low T er 
limbs are not distorted in the infant so frequently as the arms. If the 
child cannot stand, these extremities, although small and feeble, are often 
perfectly straight. In cases where the deformity of the long bones is ex- 
treme, the shaft is not only bent but broken, for a partial ("green-stick") 
fracture is generally present. The same thing is often seen in the clavicles 
which bave their normal curves very greatly exaggerated. 

Besides the softening and deformity of the bones there is another con- 
sequence of the disease which is of great importance. This is the arrest 
of growth and development of bone which can be noticed in all cases of 
severe rickets. Rickety children are short for their age, and remain under- 
sized after the disease has passed away. The arrest of growth is most 
marked in the bones of the jaws, of the lower limbs, and of the pelvis. As 
it affects the pelvis, this feature is of especial importance on account of its 
influence upon parturition in after life ; for if the capacity of the pelvic 
framework be not only diminished by distortion, but also relatively small 
from arrest of development and growth, the difficulties in the way of suc- 
cessful delivery may be insuperable. 

The weakness in the lower limbs, which is a marked feature in rickets, 
is due not alone to feebleness of the muscles combined with the general 
debility of the child. There is also great weakness and looseness of the 
ligaments of the joints. This weakness is more pronounced in cases where 
the disease begins after the end of the second year. In such cases of late 
rickets softening and deformity of bone are less common features of the 
disease, while the looseness of the joints from marked relaxation of the 
ligaments may reach a very high degree. In such cases, too, the disease 
having begun after the completion of dentition, the teeth are often white 
and sound. 

During the progress of the bone-changes which have been described, 
the general symptoms continue and become more severe. The head per- 
spirations are profuse ; the child can hardly be kept covered in his bed, 
but whether it be night or day pushes off the bed-clothes and exposes his 
naked limbs to the air. In bad cases his tenderness and dislike to move- 
ment are extreme. So long as he is left alone he is patient and still, but 



RICKETS— SYMPTOMS. 141 

when approached or noticed he at once becomes fretful and apprehensive 
of disturbance. He will sit for hours together, heedless of his toys, 
crouched up in his cot ; his legs doubled beneath him, his spine bowed, 
and his head thrown back ; supporting his body upon his hands placed be- 
fore him on the bed. On account of the softened ribs and his consequent 
difficulty in expanding the lungs, his breathing is rapid, and his whole at- 
tention seems concentrated upon the efficient discharge of this function. 
His appetite varies. Sometimes it is poor, but more often it is good and 
may be ravenous. If attention has not been paid to his diet, and the child 
continues to pass large quantities of pale, putty-like matter, he will usually 
swallow almost anything that is given to him. Sickness is not common, 
and severe diarrhoea is only occasionally met with ; but moderate attacks of 
purging are frequently seen, the stools being green, slimy, and offensive. 

The belly in rickety children is always large, even in cases where no dis- 
ease of the liver or spleen can be detected. The swelling is principally due 
to feebleness of the muscular walls, allowing of accumulation of flatus, and to 
the shallowness of the pelvis, which throws all the abdominal viscera above 
the level of the pelvic brim. If the spleen is very large it may cause a 
special swelling on the left side of the belly, sometimes reaching below the 
umbilicus. It may be remarked here that in cases where the liver and 
spleen can be felt below the level of the ribs we must not at once conclude 
that their size is abnormal. The organs may be merely pushed down by 
the depression of the diaphragm and diminished capacity of the thorax. 
Therefore, after ascertaining the position of the lower edge the upper 
limit of the organs should be estimated by careful percussion. In addition 
to enlargement of the liver and spleen the superficial lymphatic glands are 
sometimes swollen, and can be distinctly felt larger than natural, in the 
axillse and groins. 

Rickets is not a cause of pyrexia. If the temperature rise above the 
normal level a complication may be at once suspected. If fever occur 
during the stage of improvement it often announces the return of denti- 
tion, and shows that a tooth is pressing through the gum. The degree of 
wasting varies. If the disease be mild the child, although pale, is often 
exceptionally plump from over-nourishment of the subcutaneous fat ; but 
unless recovery take place shortly the limbs quickly begin to feel soft, and 
soon the child can be seen to be evidently wasting. The complexion is 
always pale, the lower eyelid is frequently discoloured, and the borders 
of the mouth have a bluish tint. If great enlargement of spleen be pres- 
ent the tint of the face becomes peculiarly bloodless and the mucous 
membranes are very pale. Rickety children are backward in every way, 
both in mind and body. Their intellect seems to grow as slowly as their 
bones. On account of their inability to join in ordinary childish games 
they are much in the society of older persons, and therefore acquire an 
unchildish way of expressing themselves ; but they talk very late and are 
dull at picking up new words and phrases. 

The progress of the disease is slow, and unless the insanitary condi- 
tions which have led to it be removed, it goes on from bad to worse. 
These children often die from some catarrhal complication. A bad diarrhoea 
is very dangerous on account of their general weakness, and a compara- 
tively mild pulmonary catarrh may prove fatal through the softening of 
the ribs. Death rarely takes place from the intensity of the general dis- 
ease. When improvement begins under judicious treatment, the general 
tenderness is usually the first symptom to subside. The child is less fret- 
ful when noticed and takes more interest in what passes around his bed. 



14'2 DISEASE IN CHILDREN. 

At the same time the softening of the bones diminishes, and as the ribs 
regain their firmness the marked improvement in breathing which results 
from the greater rigidity of the chest- wall cannot escape notice. Teething 
also begins again ; the wasting ceases ; the belly is less distended ; the 
sweats diminish and all the symptoms undergo great improvement. These 
children often become very sturdy and strong, but usually remain short in 
stature even when their full growth has been attained. 

A form of the disease has been described which has been called "acut<» 
rickets." In this variety the articular ends of the long bones undergo 
rapid enlargement and become tender on pressure. Secondary cylindrical 
swellings are also seen about the limbs. The temperature is high. It 
seems probable, from the investigations of Drs. Cheadle and Barlow, that 
these cases are instances of scurvy grafted on to rickets. They are referred 
to more fully in the chapter treating of the former disease. 

Complications. — It is not often that a case of rickets remains uncompli- 
cated by some intercurrent complaint. The subject of a pronounced form 
of rickets has but little resisting power, and is readily affected by any kind 
of injurious influence. But he is in addition peculiarly liable to certain 
forms of derangement on account of the special tendencies of this phase of 
mal-nutrition. The sensitiveness to chills manifested by a rickety child 
has been already remarked upon. This proneness to catarrh may be the 
consequence of the profuse and ready action of the sweat-glands, and it is 
no doubt encouraged by the child's practice, when his perspirations begin, 
of throwing off the coverings of his bed. The various forms of catarrh are 
therefore especially liable to occur, and pulmonary and intestinal catarrhs 
are the most frequent of these derangements. Few rickety children are 
without a cough, and this symptom, on account of the unnatural flexibility 
of their chest-walls, must be always regarded with anxiety. The danger of 
even a mild pulmonary catarrh in these patients, and the readiness with 
which this derangement gives rise to collapse of the lung, is referred to 
elsewhere (see p. 467). To this cause a large proportion of deaths is 
due. Again, more or less intestinal catarrh is a common derangement in 
this disease, and after any unusual exposure the looseness of the bowels 
may pass into a severe attack of purging. Diarrhoea, on account of the 
great general weakness, is a source of extreme danger, and during the 
changeable seasons of the year many children are carried off by this com- 
plaint. 

Another peculiarity of the rickety state is the curious impressibility 
of the nervous system which manifests itself by the ready occurrence of 
various forms of spasm. Reflex convulsions are common, and laryngismus 
stridulus is practically confined to the subjects of rickets. Catarrh of the 
larynx is also liable to be accompanied by spasm, and therefore catarrhal 
croup (laryngitis stridulosa), as is elsewhere stated, is a frequent cause of 
anxiet}'. These subjects need not be further referred to in this place, as 
they all receive consideration in special chapters. 

One other not uncommon complication is chronic hydrocephalus. On 
account of the small size of the brain in many cases of rickets, fluid is 
effused into the cranial cavity to fill up the resulting space. The amount 
of serosity is, however, seldom large and rarely comes to be a source of 
danger. 

An occasional complication, although not a common one, is acute tuber- 
culosis. The disease is probably in all cases the result of an acquired ten- 
dency due to the presence in the body of a softening cheesy deposit. It 
certainly is proportionately less frequent in rickety subjects than in children 



RICKETS — COMPLICATIONS — DIAGNOSIS — PROGNOSIS. 143 

free from this disorder of nutrition ; but it is necessary to be aware that 
rickets does not exclude tuberculosis. 

Diagnosis. — In a mild case of rickets the prominent features are the 
swelling of the epiphyseal ends of the long bones, the tardy eruption of 
the teeth, and the backwardness in learning to walk. If we notice the 
wrists to be large in a young child, we should at once count the number 
of his teeth and ask if he is able to stand alone. If a child ten months 
old shows no sign of a tooth, if his wrists are large, and if when held upon 
his feet his limbs double up helplessly beneath him, there can be little 
doubt that he is the subject of rickets. Even before the swelling of the 
articular ends of the bones has come on the onset of the disease may be 
suspected. Big, fat, flabby infants are generally slightly rickety, and if 
a child sweats profusely about the head, and is kept covered at night only 
with great difficulty, we can have little doubt that the characteristic signs 
of rickets are about to appear. In such a case attention should be at once 
directed to the child's diet, the regularity with which he is taken out of 
doors, and the state as to ventilation of his sleeping-room, so that any 
errors in management may be promptly corrected. 

In a marked case of rickets the deformity of the chest, the bending 
of the bones, the enlargement of the joints and beading of the ribs are 
sufficiently characteristic. Even the position of the patient as he sits with 
his legs crossed and his head fallen back between his shoulders, supporting 
his feeble spine by his hands placed before him on the floor, enables us at 
once to recognize the case as one of well-defined rickets. 

The complete uselessness of the lower limbs in many of these cases is 
often a serious anxiety even to parents who regard the other symptoms 
with comparative indifference, for they fear lest the child should be "going 
to be paralysed." But although the patient has no idea of even placing 
his feet upon the ground, and cries bitterly when any attempt is made to 
persuade him to do so, power of movement of the legs is unimpaired. 
If the skin of the legs be pinched or gently pricked he at once draws his 
limbs out of the way. Of other local symptoms : — The nature of the an- 
teroposterior spinal curvature is readily shown by lifting the child up 
under the arms, when the weight of the pelvis and legs at once causes the 
spinal distortion to disappear. A lateral curvature is distinguished from 
the effects of pleurisy by noting the presence of signs of rickets and the 
absence of those of effusion into the chest cavity. The rickety head differs 
from a skull dilated by excess of fluid by its shape. Instead of being glob- 
ular it is elongated from before backwards, with a characteristic squareness 
of the forehead, and moreover this shape of head is associated with other 
well marked signs of rickets. The fontanelle does not always furnish 
trustworthy evidence ; for although often depressed in rickets and raised 
in hydrocephalus, these conditions maybe reversed. Certainly a depressed 
fontanelle is compatible with a fairly copious effusion of intra-cranial 
fluid. 

In the present state of our knowledge no differential diagnosis can be 
made, during life at any rate, between rickets and osteo-malacia. Cases 
where softening and deformity of bone are present must be assumed to be 
rickets. Fortunately, for all practical purposes, a distinction in any indi- 
vidual case is unnecessary, as the measures to be adopted for the relief of 
the patient are the same whatever be the correct pathology of the osseous 
lesions. 

Prognosis. — "Rickets is not a fatal disease in itself unless the bony change 
be far advanced, nor even in such a case does death often ensue except as a 



144 DISEASE IN CHILDBED. 

consequence of some catarrhal complication. As a rule, improvement be- 
gins directly measures are taken to amend the unwholesome conditions in 
which the patieDt is living. The dangers of pulmonary catarrh and atelec- 
tasis in a child with great deformity of chest are elsewhere referred to ; 
and the serious consequences which may result from diarrhoea in an infant 
reduced to a state of' serious weakness by chronic mal-nutrition need not 
be insisted upon. Of the nervous complications, laryngismus stridulus is 
sometimes a cause of sudden death, but reflex convulsions excited by some 
trifling irritant rarely have any ill results. 

Enlargement of the spleen, liver, and lymphatic glands generally is 
very rare, but if present should excite great anxiety. It is more common 
to find enlargement of the spleen alone without any affection of other in- 
ternal organs. In rickets, as has been said, the spleen is often the seat of 
simple hyperplasia. This lesion, as it is an additional cause of anaemia, 
no doubt introduces into the case a further element of danger, but the 
danger is dependent more upon the intensity of the rickety process than 
upon the degree of splenic swelling. If the symptoms of rickets are com- 
paratively mild, and due care be taken to shield the child from catarrhal 
complications, the presence of a big spleen does not indicate the probabil- 
ity of a fatal termination to the illness. 

Age has no influence upon the prognosis of rickets, and when the 
disease occurs as a sequel of inherited syphilis, it presents no special diffi- 
culties in its treatment. 

With regard to the permanence of the unsightly deformities of bone, 
it is often astonishing to note the improvement which takes place after 
recovery from rickets in the deformities which seemed the most unlikely 
to be reduced. Large joints grow smaller, crooked bones become almost 
straight, and a distorted chest will recover itself in a surprising manner. 
In some children, however, improvement goes on farther than it does in 
others, and therefore, while encouraging the parents to believe that there 
will be considerable improvement, we must not be too sanguine as to the 
complete disappearance of all disfigurement. 

Treatment — In every case of rickets our first care should be not to give 
cod-liver oil or tonics, but to inquire into the conditions in which the child 
is living ; to ask about the food he is taking, the quantity allowed for each 
meal, the frequency with which the meals are repeated, and the degree of 
cleanliness of the feeding apparatus. We should then turn to the subject 
of his clothing, the ventilation of his bedroom, and the number of hours 
he is passing out of doors. The real treatment consists in attention to all 
these important matters, and not solely in the administration of any par- 
ticular drug. Medicines are no doubt useful as helps in the treatment, 
but their importance is trifling as compared with that of a reformation of 
the unwholesome conditions under which the failure in nutrition has taken 
place. The reader is referred to the chapter on the treatment of infantile 
atrophy for general directions with regard to the feeding and management 
of young children. 

Almost all cases of rickets have been preceded by symptoms of diges- 
tive derangement or bowel complaint, and unless improvement has already 
begun we often find signs of looseness or intestinal derangement still per- 
sisting. This should at once be remedied. The belly should be kept 
warm with an ample flannel binder, and the child should take a drop of 
laudanum to control the undue peristaltic action of the bowels, with a few 
grains of the bicarbonate of soda to correct acidity, in an aromatic water 
sweetened with a few drops of spirits of chloroform three times a day. In 



RICKETS — PROGNOSIS — TREATMENT. 145 

many cases there is a special difficulty in digesting starch. In almost all 
instances we find that this variety of food has been given in great excess. 
The quantity must be therefore considerably reduced, and that taken 
should be guarded with malt, as in Mellin's food. Hoff's extract of malt, in 
doses of two or three teaspoonfuls three times a day, is of great service in 
these cases. If the child be no longer an infant, the diet should be arranged 
as directed under the heading of " Chronic Diarrhoea " (see page 640). 

Plenty of fresh air should be insisted upon. The child, warmly clad, 
should be sent out in all suitable weathers, and if care be taken that his 
feet are well warmed before he leaves the house, there will be little danger 
of his catching cold. If the patient have reached the age of eight or ten 
months he should be carefully packed with cushions in a perambulator, 
and in cold weather should always have a hot bottle to his feet while out 
of doors. The ventilation of his sleeping-room must be attended to. A 
small fire in the winter, and a lamp placed in the fender during the sum- 
mer months, will insure a sufficient circulation of air through the bed- 
chamber. Both the patient and his immediate surroundings must be kept 
scrupulously clean. Every morning the whole body should receive a thor- 
ough washing with soap and water, and be well sponged in the evening 
before the child is put hi to his cot. On account of the copious perspira- 
tions his body linen, as well as that belonging to his cot, soon becomes 
saturated with moisture. His underclothing should therefore be changed 
as often as is necessary. Every morning, too, his mattress and bed-cov- 
erings must be thoroughly exposed to the air. The sheets also should 
be changed frequently and be carefully aired. 

If the above measures are properly attended to improvement will quickly 
begin. Directly the bowels have been got into a healthy state cod-liver oil 
should be given. A quantity much less than that usually prescribed is, 
however, sufficient ; for children, infants especially, have comparatively 
small power of digesting fats. It is best to begin with ten drops of the 
light brown oil, and during its administration the stools must be carefully 
watched for any appearance of undigested oil. The quantity can be grad- 
ually increased by a few drops at a time as long as none of the oil is seen 
to pass undigested from the bowels. Iron is also useful. Iron wine 
(TT[ xx.-xl.), the exsiccated sulphate of iron (gr. ij.-iv.), or the tincture of the 
perchloride ("f^ v.-xv.) — all these are useful, and are to be preferred to any 
of the syrupy preparations. The latter are not fitted for rickety subjects, 
as the large quantity of sugar they contain encourages fermentation and 
acidity, and often, indeed, by the disturbance it sets up in the bowels, 
makes each dose of the medicine decidedly prejudicial to the patient. If 
quinine be given, the tannate is the most suitable preparation. One or two 
grains should be suspended in glycerine and given two or three times a 
day. If there is any tendency to acidity left after rearrangement of the 
diet, the ammonio-citrate of iron may be given in a draught with a few 
grains of bicarbonate of soda and one drop of the tincture of nux vomica 
between meals. 

The salts of lime were at one time recommended in the treatment of 
rickets, as it was supposed that the bone-softening was due to a deficiency 
of lime in the system. In practice, however, the use of these drugs has 
not been found of value ; indeed, the remedy, for any special benefit it 
produces, may as well not be given at all. 

The copious perspirations from the head and neck are always a source 
of great anxiety to the mother. They can be controlled by applying bella- 
donna liniment to the parts where secretion is copious before the child 
10 



146 DISEASE IN CHILDREN. 

is put to bed. He may also take one drop of liq. atropine every night. 
Directly the tenderness has subsided steady frictions with the hand alone, 
or with olive-oil, all over the body, especially along the spine, are of great 
service and do much to strengthen the muscles. The nurse should be di- 
rected to rub the child steadily for a quarter of an hour immediately after 
his bath. In the morning the open hand or a flesh glove may be used ; in 
the evening it is advisable to employ warm olive-oil for the frictions. As 
the child improves and his strength begins to return, a cold or tepid saline 
douche, given as he sits in the warm water of his bath, will be of service. 

Care must be taken to prevent the child's getting on his feet before 
his bones are sufficiently solid to bear his weight. As his strength im- 
proves he seizes every opportunity of practising his newly acquired power 
of standing, and very marked deformities of the tibia may be produced by 
this means. In such cases support may be given to the limbs by the use 
of light, padded splints, and if the ligaments of the joints are much relaxed 
a firmly applied elastic bandage can be made use of. 

The treatment of any deformities which may remain after the complete 
cessation of the disease falls rather under the department of the surgeon. 
For the treatment of the various complications of rickets the reader is 
referred to the special chapters treating on these subjects. 



CHAPTER II. 

AGUE. 

Chtldeen who live in malarious districts are not exempt from ague ; indeed, 
in early life the system is said to be particularly susceptible to the action 
of the malarious poison. During infancy and up to the age of five or six 
years, the fever may assume peculiar characters, and unless detected early, 
and promptly treated, maj T even prove fatal. In more advanced childhood 
the symptoms present little variety from those met with in adult life. 

Causation. — Ague is an endemic disease, which is excited by residence 
in a malarious neighbourhood. An ague-breeding district is usually low- 
lying, marshy or ill-drained, and has a more or less porous soil, composed 
largely of rotting vegetable matter. Still, these conditions are not always 
found united in places where ague abounds. A disintegrated rocky soil, which 
is very porous, and is saturated with water to within a few inches of the sur- 
face, may largely generate the malarious poison, although decaying vege- 
table matter is entirely absent. A soil thus deleterious is rendered doubly 
noxious by digging below the surface. Indeed, in some cases a spot previ- 
ously healthy has been known to become malarious after disturbance of 
the soil for building or other purposes. Even a malarious district is only 
poisonous at certain seasons. In temperate climates the spring and au- 
tumn are the agueish periods of the year. In the tropics the miasma is 
evolved in the dry hot season which succeeds to the periodic rains. The 
malaria is thrown out from the soil, especially at night-time, and rises to a 
certain distance from the ground. It is always more intense near the sur- 
face, being apparently more diluted or rarified as the distance from the 
earth increases. It may be carried by the wind to a considerable distance 
from the spot where it has been generated, but appears to be incapable of 
passing a broad sheet of water, and even a band of trees is found to arrest 
the progress of the miasma. 

Amongst the residents of a malarious neighbourhood the disease is 
very common. The children living in the district are said rarely to escape ; 
for even if considered healthy they will be found, according to Steiner, to 
have the spleen enlarged. Even the new-born infants of mothers who suf- 
fer from intermittent fever may be found at birth to present the enlarged 
spleen, the bronzed skin, and all the other signs of a pronounced malari- 
ous cachexia. It has even been affirmed that the milk of a cachectic wo- 
man is capable of communicating the disease ; but this statement requires 
further proof. 

Morbid Anatomy. — When children who have been subject to ague die, 
the only constant lesion discovered is an enlargement of the spleen. Dur- 
ing an acute attack, and for some time afterwards, the organ is engorged 
with blood so as to be several times its natural size. It afterwards dimin- 
ishes in bulk ; but if the child remain in the malarious district it contin- 
ues to be harder and larger than natural. The cut surface is then pale 



148 DISEASE IN CHILDEEN. 

and dryish, with white strife from thickened trabecule, and sometimes it 
has a gray tint or even a speckled appearance from dark gray spots. The 
capsnle is thickened and often adherent. Besides the spleen, the liver is 
also congested during an acute attack, and afterwards may remain more or 
less enlarged. 

Symptoms. — In early life ague may occur either in the intermittent or 
remittent form. Both are common ; for although in the adult the remit- 
tent form is rarely seen, except in the more serious variety of the disease, 
which occurs in tropical climates, in the young child a comparatively fee- 
ble dose of the poison may produce a profound effect upon the constitu- 
tion, and excite fever of the remittent type even in a temperate zone. In 
most cases the fever is quotidian, but it may be tertian and even, although 
rarely, quartan. The three stages of the attack are usually to be recog- 
nised ; but they are less perfectly marked than in the adult, and are often 
characterised by peculiar features not found in after-life. 

As often happens in the case of the adult, the attack may not come on 
for some considerable time after exposure to the malarious influence. In- 
deed, cases are sometimes met with in which a child, who is free from fever 
while he lives in the agueish district, only begins to suffer after he is re- 
moved to a more healthy situation. 

The cold stage may begin with very violent symptoms or may give 
only trifling indications of its presence. The child may have a severe rigour 
like an adult, or may be taken suddenly with a convulsive seizure. If the 
latter the fit is rarely repeated, but is followed almost immediately by 
heat of skin and ail the symptoms of the second stage. In infants neither 
rigours nor convulsions may be seen. Instead, the baby seems drowsy ; 
frequently yawns ; sometimes stretches itself ; is peevish and fretful, re- 
fusing the bottle ; and looks pale and prostrate, with perhaps some lividity 
of the lips and finger-nails. In rare cases the hands and feet are cold to 
the touch. This stage is usually short. The temperature rises progres- 
sively throughout, and even at the beginning, when the child feels cold or 
actually shivers, is above the normal level. Towards the end of the stage 
the mercury may register between 103 and 104 degrees of heat. 

The hot stage is usually better marked. In this the skin is distinctly 
febrile ; the child is drowsy and looks ill ; if not flashed, the face is pinched 
and pale ; and the head is said to be tender. The tongue is covered with 
a yellowish fur, and according to Dr. Fruitnight it is not uncommon for the 
throat to be congested with a whitish deposit on the tonsils. The child 
is usually thirsty and drinks greedily ; he often coughs — indeed, a cough is 
said by Dr. Fruitnight to be a constant symptom of the attack ; the pulse 
is rapid, feeble, and compressible. Pressure on the liver and spleen elicits 
signs of discomfort, and both these organs on palpation are found to be 
enlarged. The child often vomits, sometimes bringing up bile ; and the 
bowels may be relaxed. Occasionally an icteric tinge is noticed on the 
skin. There is one symptom sometimes met with in a marked case which 
must not be omitted. This is a general bright redness of the surface. Such 
a rash, accompanied by a high temperature, and following rapidly upon a 
rigour or an attack of convulsions, would strongly suggest scarlatina, espe- 
cially if at the same time some redness of the throat could be detected. 
Through this stage the temperature continues to rise progressively, and 
towards the end has reached its maximum, which may be 105° or higher. 

The third or sweating stage is very imperfectly developed in the infant. 
Older children may burst out into a profuse perspiration like the adult, 
Still, whether the disease end in sweating or not, there is a remarkable 



AGUE — SYMPTOMS — DIAGNOSIS. 140 

fall of temperature at the end of the hot stage, and the thermometer will 
often mark 100° or 101° where a very short time before the pyrexia had 
been as high as 106° or 107°. At the same time that this diminution in 
the bodily heat is noticed there is usually a profuse secretion from the 
kidneys, and the child passes a large quantity of linrpid urine. According 
to Dr. Gee's observations, the proportion of urea and chloride of sodium 
are greatly increased during the hot stage, while the phosphates are 
diminished. As the temperature falls the amount of urea and of chloride 
of sodium diminish, while the proportion of phosphates is augmented. 

The duration of the attack varies. The hot stage, which lasts the 
longest, may occupy six or eight hours. After the attack is over, the child, 
if he is suffering from the intermittent form of the disease, seems quite 
well until the next attack begins. If the fever is of the remittent type, the 
patient remains more or less feverish in the interval. He is thirsty, has 
little appetite, is languid, peevish, and restless ; looks pinched and ill, and 
usually loses flesh. The wasting is sometimes increased by a troublesome 
diarrhoea. Often the fever, at first intermittent, may pass into the remit- 
tent form ; and then, again, in its progress towards recovery return to the 
intermittent type. In many cases of the remittent form of the disease the 
fever runs a less acute course, and the temperature, although };)ersistently 
elevated, does not reach the high level common in the shorter and sharper 
attacks. Thus during the paroxysms it may rise no higher than 102° or 
103°, and during the remissions may be little over 100°. 

In children of feeble constitution, or reduced by chronic disease, the 
fever may assume very malignant characters. When the attack comes on 
the patient becomes stupid and drowsy, and then quickly passes into a 
state of coma from which he never revives. Such cases are never seen in 
England. Dr. Lewis Smith states that he has twice met with this form 
of the disease, and that in each instance the attack proved fatal. 

Children who live in malarious districts often exhibit signs of ill-health 
without suffering from actual attacks of fever. Such patients are thin and 
weakly ; the skin is of a peculiar pale bistre tint ; the mucous membranes 
are pallid ; the appetite is poor, and the bowels are costive or relaxed. 
The spleen is permanently enlarged and hard. If the ansemia is extreme, 
oedema of the legs and ankles may be noticed. Sometimes, however, 
oedema in these cases is due to disease of the kidneys ; for hematuria and 
albuminuria are said to be not uncommon symptoms in children living in 
ague-breeding neighbourhoods. Indeed, in countries where malarious 
fever is prevalent the origin of Bright's disease in the child is frequently 
attributed to a previous attack of ague. Catarrhal pneumonia is said 
sometimes to complicate the illness and may even pass into confirmed 
phthisis. 

The more obscure forms of malarious fever, which are not uncommon 
in the adult, in the child are very rare. Brow ague is unknown. Bohn, 
however, states that he has met with an intermittent torticollis which he 
believed to be referable to a miasmatic cause, and Dr. Gibney has de- 
scribed an intermittent spinal paralysis also of malarious origin. 

Diagnosis. — When the disease assumes the ordinary form met with in 
the adult it is easily recognised ; but when, as often happens, especially m 
infants and the younger children, the stages are imperfectly marked and 
the symptoms indefinite, there is much difficulty in the diagnosis. If the 
case occur in an ague-breeding district, sudden illness and prostration with 
a high temperature should always excite our suspicions, especially if no 
evident cause, such as vomiting or diarrhoea, exists to explain the alarming 



150 DISEASE IN CHILDEEN. 

symptoms. Afterwards the sudden fall in the temperature which occurs 
at the end of the hot stage, and the rapid return of apparent health as the 
attack passes off— these symptoms, combined with enlargement of the 
spleen, are very suggestive of malarious origin. When on the next day, or 
the day after, the same phenomena recur, ending as before in apparent 
recovery, the nature of the illness can no longer be misapprehended. 

Fits of ague sometimes occur in children who are not at the time living 
in a malarious district. If we were suddenly called to a child of whom 
we had no previous knowledge, and found him looking ill with a very high 
temperature and signs of severe general weakness, we should be justified 
in regarding his condition with grave apprehension ; for the fact of his 
having been lately exposed to the ague poison would probably not be re- 
ferred to. In such a case, after a careful examination of the patient, we 
should be able to come to no conclusion, and might probably suspect the 
onset of one of the exanthemata. It would be only on the next visit, on 
finding the patient whom we had left in so apparently serious a state look- 
ing and feeling well, with a normal temperature, that the nature of the 
illness would suggest itself to our minds. 

If, during the hot stage, the body becomes covered with a bright red 
rash, this symptom, combined with the high temperature and perhaps slight 
redness of the throat, may raise strong suspicions of scarlatina. If, how- 
ever, we are aware that the phenomenon may occur, and find that the rash 
subsides and the temperature falls completely in the course of a few hours, 
we should reserve a positive opinion as to the real nature of the eruption. 
When, later, the same phenomena are exactly reproduced, the nature of 
the case can be no longer doubtful. Dr. Cheadle has reported two such 
cases. In one — a child aged two years and nine months — the illness 
began at 9 a.m. with a sharp rigour. A hot bath which was immediately 
given brought out a bright red rash all over the body. At the same time 
the skin was dry and burning, the temperature 102 u , and the pulse 110. 
There was no soreness of the throat. At the end of three hours the rash 
faded, and the next day the child was playing about as usual. On the fol- 
lowing day — the third — an exactly similar attack took place ; and later the 
phenomena were again repeated a third time. Quinine was then given, 
and the ague fits quickly came to an end. In a case such as the above, if 
there is no redness of the throat the resemblance to scarlatina is less 
close. Even if the throat is sore, the peculiar punctiform redness of the 
soft palate which is so common in scarlatina is wanting ; and, moreover, 
the redness in the fauces is less generally diffused. 

When ague assumes the remittent type, as it is apt to do in feeble, 
badly nourished children, the diagnosis is less obvious. In malarious dis- 
tricts it is well to suspect ague in all cases where pyrexia appears in a 
young child without evident cause. Still, the sources of error are numer- 
ous ; for a probable cause of elevation of temperature, such as dentition, 
may be present in a child who is suffering from a real agueish attack. 
Perhaps the best rule in doubtful cases is to prescribe quinine. We can 
do little harm by this practice, and may do great good by putting a stop at 
once to attacks which in weakly subjects, if not arrested early, may pro- 
duce very serious consequences. 

Prognosis. — If the disease be recognised and treated promptly it can 
usually be controlled with ease. The fatal cases are those in which the 
real nature of the illness has been misapprehended and specific treatment 
consequently withheld. Also, the exceptional cases where the child ap- 
pears to be overwhelmed by the violence of the malarious poison, and 



AGUE — TREATMENT. 151 

passes rapidly into a state of coma, are said rarely to end in recovery. 
But even in these cases, if the cause of the symptoms were recognised 
in time, it is possible that energetic stimulation and the use of quinine in 
large doses by enema or hypodermic injection might be successful in 
averting a fatal issue. It must not be forgotten that in malarious dis- 
tricts the specific fevers, and indeed acute illnesses generally, tend to run 
a more severe course than in healthier neighbourhoods, and that as a rule 
epidemics have a high rate of mortality. Children who suffer from the 
ague cachexia are bad subjects for the eruptive fevers ; and in all such 
cases we should speak with considerable caution as to the patient's chances 
of recovery. 

Treatment. — Directly the existence of ague is recognised in a child spe- 
cific treatment should be had recourse to without unnecessary delay. Chil- 
dren bear quinine well. A child of twelve months old will take a grain 
and a half of the sulphate of quinine three times a day, and the fever will 
quickly yield to this treatment. The best way of administering the remedy 
is to rub it up with glycerine and give it either in a spoon or in a wine- 
glassful of milk ; for milk helps to conceal the bitterness of the drug. 
The medicine should be continued for a few weeks after the attacks have 
ceased, but be given in diminished quantity or less frequent doses. At 
the same time it is desirable to remove the child from the malarious neigh- 
bourhood. If this be impossible, it is well to give a dose of quinine twice 
a week for a considerable time after the subsidence of the seizures. 

In cases where the child vomits the quinine, or where from other rea- 
sons it is not desired to administer the remedy by the mouth, it may be 
thrown up the bowel suspended in a small quantity of mucilage, or may 
be given by hypodermic injection. In the former case the dose must be 
double that previously recommended for administration by the mouth. 
If the remedy is administered subcutaneously, Dr. Ranking recommends 
that the neutral sulphate of quinine be used freshly dissolved in warm 
water ; that the syringe and solution be both warmed before use ; and that 
the injection be made very slowly, distributing the fluid at the same time 
amongst the interstices of the cellular tissue by the forefinger of the left 
hand, so that no lump is left to mark the site of the puncture. It is found 
thit warming the solution and the syringe not only lessens the pain of the 
operation, but also reduces the tendency of the quinine to deposit itself 
quickly in the cellular tissue. If used cold the quinine is almost always 
deposited at once in a solid mass before absorption of the solution can 
take place. This is, however, not injurious, but it retards the beneficial 
effect of the operation. The quantity of the drug thus administered 
should be a fifth of that given by the mouth. For an adult the dose is half 
a grain. Probably one-sixth of a grain would be a suitable quantity for a 
child of two or three years old. In order to prevent corrosion of the 
syringe it is advisable directly after the operation to wash the instrument 
in hot water and dry it carefully, and afterwards to oil the screw well. 
Instead of the sulphate the kinate of quinine may be used. Mr. H. Collier 
has recommended this salt as the more suitable on account of its solubility 
for hypodermic administration. 

In some cases, especially in the older children, where there is much 
acute enlargement of the liver and spleen, quinine seems to be useless. In 
these cases it is of great importance to reduce the congestion of the liver 
before beginning the quinine treatment. The child should take at night a 
dose of gray powder (gr. iv.) with jalapine or compound scammony powder, 
and the action of the bowels should be kept up for a week or two by doses 



152 DISEASE IN CHILDEEN. 

of some aperient saline. Sulphate of magnesia is very useful for this pur- 
pose, given with dilute sulphuric acid and half a grain of quinine for the dose. 
The medicine can be made palatable with spirits of chloroform, glycerine, 
and tincture of orange peel. After the liver has been unloaded, the quinine 
treatment in full doses can be returned to, or the child can take arsenic 
(ttj, v.-x. of the solution three times a day for a child ten years of age), with 
or without quinine, directly after meals. 

In the more chronic cases, a combination of quinine and arsenic with 
iron is very useful. It is also of great importance that the child be re- 
moved from the malarious district to a bracing seaside air. Moreover, he 
should be dressed from head to foot in flannel or some woollen material. 



CHAPTEE III. 

ACUTE RHEUMATISM. 

Rheumatic inflammation of the fibrous tissues is a common affliction in 
early life. In childhood, indeed, there appears to be a peculiar tendency 
to rheumatism ; and in young people the disease may assume very special 
characters. The joints are generally affected, but other fibrous structures 
suffer as well. More often than in the adult the articular inflammation is 
absent, and not infrequently it is very partial and takes an insignificant 
share in the illness. 

The great importance of rheumatism in children is due to the inflam- 
mation in and around the heart, of which it is so frequently the cause. 
The large majority of cases of heart disease are the consequence of rheu- 
matic endocarditis occurring in early life. But besides the heart other 
fibrous structures may be attacked. The pleura may be affected ; the 
meninges of the brain and spinal cord may suffer ; and sometimes fibrous 
tissues in other situations may be implicated, as will be afterwards de- 
scribed. 

Acute rheumatism is said to be uncommon under five years of age ; 
but the accuracy of this assertion is open to question. Infants and young 
children may not suffer from much articular swelling and pain, but it is a 
common experience to detect a cardiac murmur at the mitral orifice in a 
young child, and to discover, on inquiry, that the patient had some weeks 
or months previously been feverish, with a little stiffness and tenderness 
of one or more joints, symptoms amply sufficient to establish the rheumatic 
origin of the cardiac disease. 

Causation. — The principal cause of rheumatism is exposure to cold, or to 
cold and damp. In young children and infants a very slight impression of 
cold may suffice to set up the disease. Thus, I have known a young child 
exposed to draught from the nursery door, while being dried, after a bath, 
before the fire, suffer shortly afterwards from stiffness and pain in the 
knees and endocarditis. Sudden changes of temperature are favourable to 
the production of rheumatism. In England the disease is much more rife 
during the spring and the autumn, when the evenings suddenly turn chilly 
and damp, than in the winter months when the temperature is more uni- 
form. 

Many influences favour the action of cold and moisture in producing 
rheumatism. Family tendency will do this. A large proportion of rheu- 
matic children come of rheumatic parents. Again, previous illness of the 
same kind predisposes to fresh attacks. When a child has once suffered 
from rheumatism, he is very likely to suffer from it a second time. The 
state of the health at the time of the exposure exerts some influence. The 
existence of catarrh of any mucous membrane renders the patient very 
sensible to chills, and makes exposure very dangerous to a child of rheu- 



154 DISEASE IN CHILDREN. 

matic tendencies. Lastly, scarlatina predisposes with peculiar force to 
rheumatism or to a disease indistinguishable from it. 

Morbid Anatomy. — When a joint becomes the seat of rheumatic in- 
flammation, there is reddening of the synovial membrane lining the joint, 
the synovial fluid is increased in quantity and often milky, and there is 
some effusion of fluid into the surrounding tissues. Suppuration in the 
joint is very rare. 

In pericarditis the pericardium is reddened and softened, exudation 
of lymph occurs on the serous surface, and fluid is effused into the cavity. 
The serous fluid and the more solid lymph vary greatly in amount, and 
either may be in excess. The quantity of fluid thrown out is sometimes 
enormous. It may be clear or opalescent, or tinted red from blood. 
Sometimes, as in pleurisy, although far less frequently than in that disease, 
the fluid is purulent. The layer of lymph, also, may reach a great thick- 
ness. It may be smooth, or pitted with holes like a honeycomb, or ribbed 
like the sea-sand. Sometimes the visceral and parietal layers are united 
by soft thick bands of lymph. If the inflammatory process in the pericar- 
dium is severe, the heart substance towards the surface is generally sof- 
tened to a certain extent and weakened. If much lymph has been thrown 
out, more or less complete adhesion is likely to take place, after absorp- 
tion of the fluid, between the opposed surfaces of the serous membrane. 

In endocarditis the morbid appearances, when not congenital, are 
limited almost invariably to the left side of the heart. The valves become 
thickened and softened, and very soon granular on the surface. The 
granulations enlarge and develop into the so-called vegetations — out- 
growths from the fibrous tissue of the valve which may vary greatly in 
shape and size. They consist of connective tissue more or less perfectly 
organised. They are usually limited to the auricular surface of the valve, 
and are often partially covered by fibrinous deposits. Granulations may 
also develop on the chordae tendinese. The softened tissue of the valve 
may tear, or the chordse tendinese may rupture ; and the tension of the 
valve and the closure of the orifice may be seriously interfered with. After 
a time the valves may become thickened, contracted, and hardened. 
Sometimes they adhere to one another or to the wall of the ventricle. In 
this way, also, the proper closure of the opening may be impossible, and 
the opening itself may be narrowed and altered in shape. 

Ulceration may take place, seriously affecting the valve itself, and tend- 
ing to produce other grave consequences. It is the washing into the cir- 
culation of fibrinous deposits and particles of disintegrated tissue from the 
ulcerated surface that produces embolism in distant organs — the brain, the 
kidney, or the spleen. 

Symptoms. — The disease begins suddenly. The child, if old enough, 
complains of cold, and sits over the fire. He is unwilling to move about, 
sometimes vomits, and may feel some stiffness of the articulations. Soon, 
pain is complained of in one or more joints, and the child takes to his bed. 
When the patient comes under observation his temperature is moderately 
high— -102" or 103°. His skin is generally moist with a sour- smelling per- 
spiration, and on inspection we find the affected joints tender, swollen, 
and suffused with a pink blush. The child is thirsty, has little appetite, 
and his tongue is furred. The urine is high-coloured and scanty, and is 
often thick with lithates. The bowels are confined. The patient may 
wander at night ; he sleeps badly on account of the pain ; and for these 
reasons (pain and want of sleep) his face is often haggard-looking, and his 
expression distressed. 



ACUTE RHEUMATISM— SYMPTOMS. 155 

The pain is at first of only moderate severity, but gradually grows 
worse. As long as the child is quiet and undisturbed he may not make 
much complaint ; but if the limb is torched, or the bed is shaken, he at 
once shows signs of distress. The degree of pain and the amount of swell- 
ing around the joint seem to bear no relation to one another. The artic- 
ulations affected are usually the larger ones — the hips, the knees, elbows, 
ankles and wrists. It is exceptional for the small joints of the fingers 
and toes to be painful and swollen. "Usually one or two joints are first 
attacked ; these recover, and others become inflamed. The whole illness 
may last a variable time, but the duration of the inflammation in each 
particular joint is comparatively short. It may pass away in a few hours, 
and rarely lasts longer than a day or two. Sometimes, after leaving a joint 
and passing to another, the inflammation returns to the joint first affected; 
and in this way, if the illness be a long one, the same joint may be at- 
tacked again and again before the energy of the disease is exhausted. 
Even when the attack appears to be at an end, a sudden return of the symp- 
toms may distress and disappoint the patient and his friends. Eelapses are 
very common in rheumatic fever, and the symptoms may return, after a 
more or less complete subsidence, two, three, four, or even five times. 

The articular inflammation, although the part of the disease which 
causes the greatest discomfort to the patient, is yet, as it seldom produces 
after ill-consequences, of comparatively trifling moment. A far more im- 
portant feature is the heart affection, wdiich is so common an expression of 
the malady. Inflammation of the fibrous structures in and around the 
heart is an essential part of the disease, as it attacks young persons, and 
must not be regarded as a mere casual complication. In exceptional 
cases, indeed, a child may have rheumatic fever and the heart may escape ; 
but in rheumatism all the fibrous structures of the body need not be af- 
fected at once. The patient may have inflammation of one joint and 
not of another ; the right wrist, for instance, may be affected and the left 
may escape ; one leg may be Crippled and the other sound. So the disease 
may attack the joints and. leave the heart alone, as it may attack the heart 
and spare the joints. The younger the child the more likely is it that the 
disease w r ill fasten upon the heart to the exclusion of the articulations. 

The occurrence of rheumatic inflammation of the heart and pericardium 
is not at once announced by any striking change in the symptoms, or even 
in the aspect of the patient. Indeed, it is matter for surprise how complete 
in most cases is the absence of all external indications that so important an 
addition has been made to his illness. Often the only sign of implication 
of these organs is derived from physical examination of the chest. 

In rheumatic inflammation of the pericardium there is in ordinary cases 
neither pain nor tenderness ; w T e notice no special hurry of breathing or of 
pulse ; the heart's action may be irregular, but there are no palpitations ; 
there is little change of colour in the face ; and, unless the joint affection 
be severe, the temperature may be only moderately raised, or may even be 
normal. In spite, however, of the absence of symptoms, the child looks 
ill ; and while up and about — as he usually is before coming under the no- 
tice of the medical attendant, if the articular inflammation is not severe — 
his countenance wears an expression of distress which quickly attracts the 
attention of his friends. 

A little girl, aged three years and a half, was admitted into the East 
London Children's Hospital. She had had a slight cough for a fortnight, 
and was said to have looked ill. On examination, there was found dul- 
ness of pyramidal shape in the precordial region reaching upwards to the 



156 DISEASE IN CHILDKEN. 

left sterno-chondral clavicular, and to the right as far as one finger's- 
breadth beyond the right edge of the sternum. The apex-beat of the heart 
was behind the fifth rib, slightly to the inner side of the nipple line. A 
faint impulse was felt all over the praecordium. The heart-sounds were 
muffled, and a soft double friction-sound was heard at the base. The child 
complained of no pain. There was no affection of the joints. The other 
organs were healthy and the temperature* was/ normal. A week aftei - 
wards it was noted : " The cardiac dulness is as at last report, and there" 
is the same friction to be heard over the precordial region. Since admis- 
sion the child has had no symptoms, and the temperature has been gen- 
erally subnormal. Still the patient looks ill, and there is a distressed ex- 
pression on the face even during sleep. Is now (3 p.m.) lying asleep on her 
back, inclining to the left side. Pulse 88, regular ; respiration 28, nares not 
acting. Some slight lividity about the mouth and under the eyes. Gen- 
eral pallor of face, with a faint tinge of pink on her cheeks. Lips rather 
pale. The superficial veins are visible over the sides of the neck and the 
backs of the hands, although not greatly enlarged." After a few weeks the 
physical signs of the heart became normal, and the child's health was per- 
fectly restored. 

The above illustrates very well the general appearance of a child who is 
the subject of pericarditis. In the large majority of cases, although he may 
look ill and be languid, yet if there be no joint affection, he makes no spe- 
cial complaint. An examination of the chest at once reveals the cause of 
the indisposition. 

Still, it is right to say that in exceptional cases much more serious symp- 
toms may be noticed. There may be tumultuous action of the heart, with 
great dyspnoea or even orthopncea, and lividity of the face. The counte- 
nance may express the utmost anxiety, and the restlessness may be extreme. 
There is usually, also, some puffiness of the face, and slight but general 
oedema. The gravity of these cases is probably owing to the participation 
of the heart substance in the inflammation. Again, in still other cases we 
find symptoms all pointing to the brain. There is high fever, with head- 
ache and delirium (see page 159). Such cases are, however, chiefly inter- 
esting from their rarity. They occur very seldom even in hospital prac- 
tice, and are clinical curiosities which for practical purposes may be put 
on one side. 

The beginning of pericardial inflammation is indicated by a more or 
less loud rub of friction accompanying the sounds of the heart, The rub 
is best heard at the base, and is double, the systole and diastole being ac- 
companied by a distinct catch or scrape, which is very superficial, and con- 
veys the impression of being generated at a point nearer to the ear than the 
sounds of the heart themselves. Even if there be at the same time an en- 
docardial murmur, the friction sound can be in most cases readily sepa- 
rated by the practised ear, through its higher pitch and more superficial 
character, from the lower pitched and more deeply sounding murmur gene- 
rated by the inflamed valve. A pericardial friction-sound is not, however, 
always high pitched, and even its superficial character may not be so de- 
cidedly marked as would be expected. In certain cases a loud blowing 
sound is heard, which is indistinguishable by the ear alone from a similar 
sound of endocardial origin. Its mechanism must be then decided by 
other considerations. 

At first there is no alteration in the precordial dulness, but in a day 
or two, as fluid is poured out from the inflamed serous membrane, the 
limits of the heart's dulness are extended. At the same time the position 



ACUTE RHEUMATISM — SYMPTOMS— PERICARDITIS. 157 

of the apex-beat of the heart is raised, and the cardiac impulse is feebler 
than before. 

A little girl, aged seven years, had a mild attack of rheumatism fol- 
lowed by chorea. Six months afterwards the choreic movements returned, 
and she was admitted into the East London Children's Hospital. At this 
time the heart's apex was noted to be beating between the fifth and sixth 
ribs, one-fourth of an inch outside the nipple line ; and a soft systolic 
murmur was heard at this spot. After being a few days in the hospital, 
the child's temperature rose from normal to 103.8°, and a double rub was 
detected over the precordial region. There was also a patch of imeumo- 
nia at the base of the right lung. Some days afterwards effusion was 
found to have occurred in the pericardium, the limits of the heart's dulness 
were extended, arid the heart's apex was raised to between the fourth and 
fifth ribs in the nipple line. The double friction was still heard — most 
distinctly at the level of the third left sterno-chondral articulation. 

If much lymph and little fluid be thrown out, the hand placed upon 
the precordial region can often detect a distinct fremitus with each beat 
of the heart. When a considerable quantity of fluid is effused into the 
pericardium, the resulting area of dulness takes the shape of the contain- 
ing sac. It becomes triangular or "pyramidal" in form, with the ajDex di- 
rected upwards towards the top of the sternum. A moderate effusion does 
not prevent the friction-sound from being heard, but the rub becomes less 
intense and less crisp than before, and the heart-sounds are muffled and 
distant. In great effusion the chest-wall in the cardiac region may be 
bulged, and on careful inspection the eye can often detect a distinct 
undulatory movement with each beat of the heart in the intercostal 
spaces. 

An important distinguishing mark of pericardial friction is, besides its 
superficial character, the irregularity of distribution of the sound. Endo- 
cardial murmurs are carried along with the blood-current. Pericardial 
frictions may be limited to a small area, or heard equally loudly over the 
wdiole precordial region ; in either case they do not follow the rules 
which regulate the transmission of heart-murmurs. Further, a pericardial 
rub is intensified by pressure, and is heard better during expiration than 
when the lungs are expanded. As the fluid and lymph become absorbed, 
the limits of dulness gradually return to their former dimensions ; and the 
friction after a time becomes fainter and fainter and gradually disapi:>ears. 
If the lymph has been exuded in large quantity, adhesion of the pericar- 
dium may take place. Unless there be also adhesion between the pericar- 
dium and the adjacent pleura, there are no physical signs by which this 
condition can be detected. If the pleura and pericardium be adherent, 
the intercostal space corresponding to the apex of the heart is depressed 
at each impulse. Adherent pericardium is generally followed by hyper- 
trophy of the heart. 

The fluid in pericarditis sometimes becomes purulent. The suppu- 
rative form of pericarditis is more common in cases where the inflammation 
has extended to the pericardium from the pleura ; although it may no 
doubt also occur without the pleura having been previously affected. In 
the cases of this form of pericardial inflammation which have come under 
my notice, the patients have complained of pains in the chest or epigas- 
trium ; the temperature has been high at night (103° to 101°), with a par- 
tial morning remission ; pericardial friction has disappeared early ; ab- 
sorption of the effusion, if it had begun at all, has been slow and incom- 
plete, and towards the end of the disease slight but general oedema has been 



158 DISEASE IN CHILDEEN. 

noticed without any albumen being discovered in the urine. These cases 
almost always end fatally. 

When endocarditis occurs, the valvular lesion is indicated at first by 
no external signs, and can only be discovered by physical examination. 
With the stethoscope we hear a low-pitched soft murmur at some point of 
the precordial surface, indicating, according to its site and rhythm, ob- 
struction or incompetence of one or another of the cardiac valves. The af- 
fection of the valve may be accompanied by increased frequency of the 
pulse and some palpitation ; but while the patient is at rest in bed these 
symptoms are very exceptional. Tenderness is never present, and it is 
rare for the child to complain of pain or uneasiness about the chest. The 
valve affected is most commonly the mitral, although the aortic semilunar 
valves are sometimes inflamed alone, or in conjunction with it. The le- 
sions are almost invariably limited to the left side of the heart. 

Endocarditis may occur without implication of the pericardium, or the 
two lesions may be combined. In the latter case the endocardial murmur 
may be completely masked by the external friction-sound, and may only be 
discovered as the latter subsides. If unaccompanied by inflammation of 
the pericardium, endocarditis, although a very serious misfortune as re- 
gards the future of the patient, adds little, if anything, to the immediate 
danger. 

There is one accident which sometimes occurs as a direct result of en- 
docarditis. The vegetations on the inflamed valve may undergo disinte- 
gration, and minute particles swept away into the general circulation may 
become arrested in the small arteries of a distant organ. Ulcerative en- 
docarditis is not a common disease in children, but it is occasionally met 
with. This complication gives rise to symptoms which may be mistaken 
for those of pyaemia or of continued fever, so close sometimes is the re- 
semblance. They are partly constitutional, owing to admixture with the 
blood of decaying atoms of organic matter from the disintegrating valve ; 
partly local, from embolisms which interfere with the function of special 
organs. Thus there is high fever with marked remissions ; great weak- 
ness and prostration ; a furred dry tongue ; often sickness, and perhaps 
diarrhoea, thirst, and anorexia. The pulse is small, rapid, and weak ; the 
breathing hurried ; and the child gradually becomes restless and deli- 
rious, or drowsy and comatose. The local symptoms are derived from the 
organ or organs, whose function is interfered with by arrest of emboli in 
their minute arteries or capillaries. Thus, embolisms in the skin produce 
petechi&e from minute extravasations ; in the liver, swelling and perhaps 
jaundice ; in the kidney, albumen and blood in the water ; in the spleen, 
swelling and tenderness ; in the brain, paralysis ; or if from small dissemin- 
ated emboli, headache, delirium, and coma, without special interference 
with motor function. In all these cases examination of the heart reveals the 
signs of valvular disease. The cases generally end fatally. 

The pleura is often affected in rheumatism, alone or in conjunction with 
the pericardium. Pleurisy and pericarditis may occur simultaneously, or 
the inflammation may spread from one membrane to the other. When 
the two diseases are present together, the inflammatory processes in the 
two situations may be perfectly independent the one of 'the other. The ef- 
fusion in the pleura may be purulent, and that in the pericardium serous ; 
or the pericardium may contain pus, and the pleura pure serum. 

A little boy, aged six years, died in the East London Children's Hos- 
pital of pleurisy and pericarditis. On examination the right lung was 
found adherent to the pericardium, and partially to the chest wall. It was 



ACUTE RHEUMATISM — CEREBRAL SYMPTOMS. 159 

condensed and tough from pressure, and the pleura of that side contained 
a large quantity of clear fluid. The pericardium was adherent to the heart 
in places, and in the sac were about two ounces of thick pus. In this case 
the illness had begun with sickness and pain in the side, followed by cough 
— symptoms which pointed to pleurisy ; and three weeks afterwards, when 
the child first came under observation, there was slight but distinct con- 
traction of the right side, shown by lowering of the shoulder and angle 
of the scapula, with distinct curving of the spine — the convexity to the 
left. These signs, taken in conjunction with the history, seemed to indi- 
cate that the pleurisy had dated from the beginning of the illness, and 
that therefore, if it did not give rise to the pericarditis, was not, at any rate, 
secondary to it. 

Pneumonia is not rare in rheumatic fever, and may occur in conjunc- 
tion with pleurisy or independently of it. A much rarer lesion is menin- 
gitis affecting the membranes at the convexity of the brain and those of 
the spine. These cases are characterised by high fever, headache, and de- 
lirium. Still, we must not suppose that in every instance where such 
symptoms occur in the course of acute rheumatism they are due to inflam- 
mation of the cerebral meninges. Many cases are now on record in 
which these symptoms have been present, with others — all pointing to the 
head as the seat of the lesion, and yet on dissection of the dead body no 
signs of disease have been discovered within the cranium. Dr. Latham 
has described a case of this kind which occurred in a little scholar at Christ's 
Hospital. The boy had high fever, headache, delirium, and convulsions ; 
and died in spite of energetic treatment directed against a supposed men- 
ingitis. Examination of the body disclosed no disease of the brain or its 
membranes ; instead, there were all the signs of a severe pericarditis — a 
disease which had not been so much as suspected during life. Trous- 
seau believed this form of " cerebral rheumatism," which leaves no trace 
of intracranial inflammation behind it, to be a neurosis depending upon 
some such mysterious modification of nerve-substance as is believed to oc- 
cur in hysteria and tetanus. The symptoms may, however, be explained 
more simply by attributing them merely to the effects of hyperpyrexia ; 
and this is the view commonly accepted in the present day. Such a case 
has never come under my observation ; nor have I ever seen a case of 
rheumatic iritis in the child, nor of peritonitis occurring in the course of 
acute rheumatism. 

Peritonitis may, however, be simulated by rheumatism of the abdomi- 
nal muscles which sometimes occurs in children. If this be severe, there 
is tenderness on pressure of the abdominal wall, the child may have an 
appearance of great distress, and may lie in bed with his knees flexed on 
his abdomen, as if he were really suffering from inflammation of the peri- 
toneum. The bowels are usually confined. These cases may be readily 
distinguished by careful examination. The face, although often distressed, 
has not the haggard look which is so characteristic of peritonitis ; there is 
little or no tension of the abdominal wall ; the natural markings are not 
lost ; the tenderness is not extreme ; the pulse is soft, compressible, and 
of moderate quickness, not rapid and hard ; and the temperature is normal 
or only slightly elevated. There is generally great acidity of urine ; it is 
scanty and high-coloured, and its passage may cause some scalding. 

Torticollis (stiff-neck) is sometimes a consequence of rheumatism. The 
disease may aifect the muscles, especially the sterno-mastoid ; or may at- 
tack the fibrous ligaments uniting the vertebrae. The nervous system, too, 
may suffer. Neuralgia has been noticed in some children ; and paralysis 



160 DISEASE IN CHILDREN, 

of the muscles of one side of the face may be produced by rheumatic in- 
flammation of the sheath of the facial nerve at its point of exit from the 
bone. Moreover, there is an evident connection between rheumatism and 
chorea. This important subject will be considered elsewhere (see Chorea). 

A peculiar manifestation of rheumatism is sometimes found in chil- 
dren. This was first noticed by Meynet, and is characterized by swellings 
varying in number and size which appear in the tendons and their sheaths, 
and in other fibrous structures which lie close under the skin. Thus they 
are seen around the patella and the malleoli ; on the spinous processes ; on 
the temporal ridge, and on the superior curved line of the occiput. They 
are very hard ; are accompanied by no redness, tenderness, or pain ; are 
sometimes movable ; and disappear after a time spontaneously. They 
are composed of small masses of loose fibrous bundles, and are very vas- 
cular. 

A little girl, nearly ten years old, was under my care in the East Lon- 
don Children's Hospital for an attack of rheumatic fever complicated with 
chorea. She had a harsh systolic murmur at the apex of her heart, which 
evidently dated from a previous attack of endocarditis ; but the apex-beat 
was not displaced, nor were the normal limits of the heart's durness ex- 
tended. In this child fibrous nodules were found on the spinous processes 
of the vertebrae, the prominences of the scapula, the head of the radius, 
the tendons in front of the right ankle, and the back of the right hand. 
The nodules varied in size from a split pea to a large marble ; they were 
not tender, and the skin over them was not adherent. While the child re- 
mained in the hospital her temperature never at any time rose above 100°. 
The swellings gradually diminished in size, and by the end of the month 
had almost completely disappeared. 

The duration of the rheumatic attack is much longer in some children 
than in others. It may be variously estimated according to the method 
upon which the reckoning is conducted. If we take into account merely 
the joint affection and the general symptoms, the disease may be considered 
over in a few days. A child may be taken with high fever, and complain 
of pain in one or other of his joints, which is found to be red, swollen, and 
tender. In twenty-four or forty-eight hours the articular inflammation 
may be at an end and the temperature normal. But it does not follow 
that the disease is over ; and if we at once begin to treat the child as a 
convalescent, we may find reason to regret our precipitation. Serious in- 
flammation of the pericardium and lining membrane of the heart is quite 
compatible with a normal temperature ; and these internal lesions may be 
only beginning when the external signs of the disease are on the wane. As 
it is only in exceptional cases of rheumatic fever that the heart does not 
suffer, and as the mildest attack of pericarditis is seldom over before a 
week has gone by, eight or ten days must be considered the earliest period 
at which convalescence can be said to begin. 

In other cases, if there are frequent relapses, the disease may be pro- 
longed for many weeks, the inflammation leaving joints and returning to 
them with wearisome repetition, and the pericardial inflammation waxing 
and waning with similar persistency. In this way an attack may be made 
to last six weeks or two months. It is, however, only right to say that 
since the introduction of the salicylates these cases are much rarer than 
they used to be. 

Although the joint affection in rheumatism is usually an acute disease, 
and ceases when the attack is at an end, yet this is not always the case. 
Children with strong rheumatic tendencies, and who have had several at- 



ACUTE RHEUMATISM — DIAGNOSIS. 161 

tacks of rheumatic fever, may complain of wandering pains in the back, 
neck, and loins, and of transient discomfort and stiffness in a joint from 
time to time, especially in the variable seasons of the year, without having 
to take to their beds. In such patients there is general impairment of 
health, appetite is poor, and nutrition is unsatisfactory. The child is 
often excessively nervous, sleeps badly at night, and is changeable in tem- 
per. Dr. West has connected these symptoms with the lithic acid diathe- 
sis. There is no doubt that such children are subject to sandy deposits 
in their urine, and to abundant secretion of urea. 

Diagnosis. — When the joint affection is well marked it can scarcely 
be mistaken. An acute articular inflammation which .flies from joint to 
joint capriciously, is accompanied by redness, swelling, and extreme ten- 
derness, and in a day or a couple of days has passed completely away 
from the joint first attacked, to run the same rapid course in another — 
such a disease can only be rheumatism. Keal rheumatic joint affections 
are very transitory. If redness, pain, and swelling persist in a joint supposed 
to be rheumatic, we may suspect strongly that the true cause of the lesion 
has yet to be discovered. It is often difficult to decide the nature of the 
obscure pains and stiffnesses from which some children suffer. The so- 
called "growing pains " are often rheumatic in their origin ; and if they 
occur in children of decided rheumatic family tendency, should be re- 
garded with extreme suspicion. A careful examination of the chest will 
often clear up obscurity, and it is unfortunately too common to find serious 
valvular or pericardial mischief associated with a very trifling amount of 
articular or even muscular pain in young subjects. A to-and-fro friction 
sound over the precordial region, if decided, is very suspicious in itself of 
pericardial inflammation. If the child look ill, and especially if there be 
also increase of the heart's dulness, the evidence in its favour is complete. 
A faint double rub at the base of the heart is not in itself sufficient to es- 
tablish this conclusion ; for such a friction may be produced by slight 
roughness of the pericardial surface, from prominent vessels or other cause, 
when the membrane is quite free from inflammation. 

Dulness of pyramidal shape in the precordial region, although very 
suspicious of pericardial effusion, is not conclusive ; such a dulness may be 
produced by a mass of enlarged glands in the anterior mediastinum. Ex- 
tension of dulness to the left, beyond the point at which the apex beats, 
is said to be a positive sign of effusion. The increase in the dull area 
when the patient is placed in the erect position is often absent ; when 
present, it is, no doubt, an additional proof of fluid accumulation in the 
sac of the heart. 

When the fluid becomes purulent, as it may do at an early date, the 
nature of the contents of the sac may be inferred from the variable 
temperature, the mercury rising every night to 104° or 105°, and sinking 
in the morning to the normal level, or even below it ; the early subsidence 
of the friction, although the amount of the effusion remains unchanged ; 
the stationary character of the dulness, showing want of absorption of the 
fluid ; and the appearance, after a time, of more or less general oedema 
without albuminuria. 

On account of the frequency with which pericarditis and pleurisy are 
combined in young children, we should never neglect to make a careful 
examination of the heart in every case in which we have ascertained the 
existence of pleural inflammation. Pericarditis, under these circumstances, 
is not easy to detect, as the dulness in the precordial region is attributed 
to the effusion in the chest cavity. Unless, however, the pleural effusion 
11 



162 DISEASE IN CHILDEEN. 

be very great, the percussion note in the infra-clavicular region is very 
different from that obtained in the prsecordia. If, therefore, we find com- 
plete dulness towards the upper part of the sternum, and a fairly resonant 
or wooden note below the clavicle near the acromial angle, we may strongly 
suspect accumulation in the pericardial sac. Friction over the heart may 
then be generally heard on careful auscultation. 

A difficulty sometimes arises in these cases from a pleural friction of 
cardiac rhythm being heard at the limits of the pericardium. This is owing 
to the action of the heart causing a movement between the adjacent pleural 
surfaces. In these cases if the child be old enough, or sufficiently amia- 
ble, to follow directions, we should listen at the seat of friction while the 
breath is held after forced expiration, and if the rub cease or be heard 
only at this spot, it is probably due to the cause referred to. It is not 
always possible, however, positively to exclude pericarditis. 

If we hear a blowing murmur at the apex of the heart, the question of 
valvular competence has to be considered. All blowing murmurs at the 
apex must not be taken to indicate regurgitation, nor, indeed, are they a 
positive sign that the endocardium is inflamed at all. The murmur may 
be the consequence of regurgitation, of roughness of the valve or cardiac 
lining, of anaemic dilatation of the ventricle, or of mere abnormal tension 
of a healthy valve, and there is nothing in the quality of the sound to show 
to which of these causes it may be properly assigned. If, however, the 
second sound is evidently intensified over the pulmonary artery ; if the 
murmur is heard at the angle of the scapula ; and if, with a full contrac- 
tion of the left ventricle, the pulse is feeble, small, and irregular, we may 
confidently pronounce the mitral valve to be insufficient. Still, regurgi- 
tation may take place without giving rise to these signs. Therefore, in 
most cases we must reserve a positive opinion, and wait until sufficient 
time has elapsed to allow of nutritive changes taking place in the wall of 
the heart. If there be no displacement of the apex-beat at the end of 
twelve months, we may be satisfied that the cause of the murmur is not 
regurgitation. 

A recent murmur is very soft in quality and of low pitch. After being 
in existence for some months it becomes harsher and its pitch rises. If in 
a case of acute rheumatism we hear a harsh and loud endocardial murmur 
at the apex, we may be sure, whatever its mechanism, that it is not of re- 
cent origin, but is a relic of some former attack. 

The diagnosis of ulcerative endocarditis has been already sufficiently ex- 
plained. If we find that a child, who has lately suffered from an attack of 
acute rheumatism with endocarditis, remains feverish, with rapid elevations 
and depressions of temperature, such as are characteristic of suppuration ; 
if he pass quickly into a typhoid state with dry brown tongue, loss of ap- 
petite, hurried breathing, and signs of great prostration, we should sus- 
pect the presence of this complication ; and if we find evidence of embol- 
isms in special organs, our suspicions are sufficiently confirmed. 

Prognosis. — The immediate prognosis of acute rheumatism is seldom 
otherwise than favourable. Even the existence of endocarditis and inflam- 
mation of the pericardium cannot often be regarded as giving rise to any 
fear of immediate danger. Still, it is well not to speak too positively in 
predicting a favourable issue to the illness. In acute rheumatism — even in 
the mildest cases — there is a tendency to hyperinosis ; and the rapid for- 
mation of a clot in the right ventricle of the heart or in the pulmonary 
artery may be a cause of sudden death. In some instances this distress- 
ing accident happens quite unexpectedly in a case which is running a fa- 



ACUTE RHEUMATISM — PROGNOSIS — TREATMENT. 163 

Yourable course, and may even occur at a late period of the disease after 
convalescence lias seemed to be established. Again, in rare cases, pericar- 
ditis is a cause of death. "When the effused fluid is or becomes purulent, 
the danger is great ; and few such cases recover. 

The ultimate consequences of an attack of rheumatic fever may be very 
serious, for the large majority of cases of heart disease can be referred to 
this cause. But, as already remarked, the mechanism of heart-murmurs 
is so various, that the mere existence of a blowing sound at the apex of 
the heart is no indication in itself that serious consequences are to be ap- 
prehended. If the child be seen during an attack, or while the murmur 
is still recent, it is impossible to speak with certainty as to the gravity to 
be attached to the phenomenon. If, after a time, we discover signs of di- 
lated hypertrophy of either ventricle, with displacement of the heart's 
apex, and accentuation of the second sound at the pulmonary cartilage, 
we may positively assume that serious incompetence exists of the mitral 
valve. 

Endocardial murmurs arising during an attack of rheumatism in chil- 
dren sometimes disappear. It is probable that in all these cases the mor- 
bid sound was generated by other mechanism than valvular incompetence, 
for I have never known the auscultatory sounds to become healthy except 
in cases where the heart's apex has retained its normal situation. 

A little boy, aged eighteen months, with sixteen teeth, was brought to 
me in November, 1874. A few months previously he had seemed to have 
pain and stiffness in some of his joints, and had been a little feverish. 
Since that time he had been subject to palpitations which were sometimes 
violent. On examination I found a loud basic systolic murmur conducted 
to the second right cartilage, and at the apex a less loud mitral mur- 
mur. The apex-beat was normal. In March, 1875, I saw the child again. 
The apex-beat was still in normal site. The heart-sounds were a little 
muffled to the ear, although no murmur could be heard at either the base 
or the apex ; but on this occasion no attempt was made to excite the heart's 
action. The patient was seen for the third time in March, 1881. He was 
now nearly eight years old, and of average height for that age. Although 
rather thin, he was stated to enjoy good health, and never complained of 
palpitations or of breathlessness. The position of the apex-beat remained 
unaltered. The first sound was muffled, and after the boy had been made 
to run round the room, a faint systolic murmur was developed at the apex. 
It could not be heard at the angle of the scapula. 

In this case the basic murmur disappeared, and that at the apex be- 
came so indistinct that it could only be detected by exciting the heart's 
action. Whatever may have been the cause of the abnormal sounds first 
heard, they were apparently the consequence of rheumatism. Still, it 
seems certain that there could have been no organic lesion of valve, for in 
the course of nearly seven years no alteration in the nutrition of the heart 
had taken place. 

Treatment. — A child the subject of acute rheumatism must be kept in 
bed ; the inflamed joints must be wrapped in cotton wool, kept in place by 
a firmly applied flannel bandage ; and the chest should be also enveloped 
in the same material. A mercurial purge should be given to produce free 
action of the bowels ; and salicylate of soda should be administered with- 
out unnecessary delay. Children, as a rule, bear this remedy well. It is 
exceptional to find any ill effects resulting from its employment. For a 
child of five years old, ten grains of the salt may be given every two or 
three hours with tincture of orange peel and glycerine. Within two 



164 DISEASE IN CHILDKEN. 

or three days, sometimes within a few hours of beginning the^ treatment, 
the temperature falls, the pulse becomes less frequent, and the joint symp- 
toms are moderated. The pulse usually loses in strength as well as in 
frequency ; and the depression induced by the action of the drug upon 
the muscular fibres of the heart is sometimes so great that its administra- 
tion has to be supplemented by the free use of stimulants^ This effect of 
the remedy is, however, less common in children than it is in the adult, 
and I have rarely been obliged to discontinue its use for this reason. It 
sometimes causes distressing vomiting, and occasionally excites epistaxis 
which may be obstinate. If, on account of any of these accidents the 
treatment has to be suspended before the disease is completely subdued, 
the temperature often rises again, and the joint affection may return. 

In a small minority of the cases the medicine, although well borne, ap- 
pears to exercise no influence upon the disease, and even when it lowers 
the temperature and subdues the joint affection, it seldom prevents the oc- 
currence of cardiac or pleural inflammation. The first signs of pericar- 
ditis may be noticed when the patient appears to be under the influence 
of the remedy ; and I cannot say that in any case the course of the peri- 
cardial disease has appeared to me to be shortened by the use of the sali- 
cylate. Still, if only for its influence in reducing temperature and check- 
ing articular inflammation, the drug would be a most valuable one, and we 
should not be doing our duty to the patient if we neglected to employ it. 

In cases where the salicylate cannot be used, we may adopt the alkaline 
treatment, giving bicarbonate of potash in ten-grain doses every three or 
four hours. If thought advisable, the bicarbonate may be combined with 
quinine ; or we may prescribe a mixture of quinine with iodide of potas- 
sium, as recommended by Dr. Greenhow. The objection to the alkaline 
plan of treatment is that it encourages the tending to anssmia. It should 
therefore be supplemented by the early administration of iron when the 
joint pains have subsided. The method of treatment advocated by Dr. 
H. Davis, which consists in encircling the affected joint with a thin line of 
blistering fluid is a painful proceeding and ill-suited to young patients. 
The best local application is a thick layer of cotton wool, with a firmly ap- 
plied flannel binder. 

If there be much pain in the joints, a small dose of Dover's powder can 
be given at night (gr. ij.-iij. to a child of four or five years old). Chloral 
must not be used during the administration of the salicylate, as it also has 
a depressing effect upon the heart. 

Hyperpyrexia is not common in cases of rheumatic fever in children, 
and, indeed, it is difficult to say what degree of elevation of temperature can 
in an ordinary case be accounted hyperpyrexia in a child. An injurious 
amount of fever is usually accompanied by symptoms of mental disturb- 
ance such as are characteristic of the so-called " cerebral rheumatism." 
If these are absent, it is unnecessary to attempt to reduce the temperature 
by baths ; unless, indeed, the pyrexia persist and seem to be injuriously 
affecting the patient's strength. I have never seen a case of rheumatic fe- 
ver in a child in which I have felt it necessary to employ cold. 

The diet in acute rheumatism must be simple. While the fever per- 
sists the child should take nothing but milk and fresh-meat broths, with a 
little dry toast. When the temperature falls, a more generous diet may 
be allowed ; but for some time attention should be paid to the quantity of 
fermentable matter, such as starches and sweets, taken by the child. The 
appearance of lithates in his water is a sure sign that some modification in 
his diet is required. 



ACUTE RHEUMATISM— TREATMENT. 165 

Directly the existence of pericarditis is ascertained, a blister should be 
applied over the precordial region without loss of time. I prefer the 
blistering fluid for this purpose as most certain in its action, and use it 
to quite young children. It is of extreme importance to check the peri- 
cardial inflammation early, and there are no means at our command so 
efficacious for this purpose as a blister. In many cases the effusion begins 
to disappear as the blister rises. If there be much effusion, and the joint 
affection have subsided, I am in the habit of giving large doses of the io- 
dide of potassium, alone, or with the tartrate of iron. The iodide is in 
my opinion of great value in removing serous effusions, if given in full 
doses. To a child of five or six years of age I give ten grains of the io- 
dide three times a day, and have never seen ill effects follow its employ- 
ment. On the contrary, its value in causing absorption and restoring the 
natural state of the membrane has appeared to me to be very decided. 

In endocarditis, also, blistering should be employed ; and if the tem- 
perature has fallen, iron and quinine should be prescribed. The same 
tonic treatment can be adopted in cases of pericarditis after absorption of 
the effusion, for the patient is usually left anaemic and weak from the at- 
tack, especially if he have been treated with the salicylate of soda. In all 
cases where the disease has been complicated with endocarditis it is ad- 
visable to keep the child in bed as long as possible,; and even when he is al- 
lowed to get up it is wise to enforce the utmost attainable quiet. In these 
cases the heart is more likely to recover itself if its action be not excited ; 
and, indeed, judicious care during convalescence may largely influence the 
future well-being of the patient. Complete rest moderates the heart's ac- 
tion, and allows time for the healthy removal of inflammatory products from 
the valves. If such products become organized, they contract the tissues 
and cause puckering of the valves, with all the evils which the resulting 
hindrance to the circulation must inevitably entail. 

If suppuration in the pericardium is suspected, the sac should be care- 
fully punctured with a hypodermic syringe in the fourth or fifth interspace, 
near the left edge of the sternum, to make sure that the fluid is purulent. 
If it prove to be so, the question of evacuating the contents of the peri- 
cardium must be considered. Professor Eosenstein has reported an interest- 
ing case, in a boy of ten years of age, in whom recovery took place after the 
sac had been emptied. The pericardium was opened by incision in the 
fourth space, near the sternum, and after the pus had escaped, two drain- 
age-tubes were passed into the wound, and antiseptic dressings were em- 
ployed. This form of pericarditis is so fatal that the operation should be 
decided upon if the state of the patient offer the slightest prospect of its 
success. 

Muscular rheumatism, whether it affects the abdominal wall or the 
muscles of the neck, must be treated with stimulating applications and 
with warmth. A good mercurial purge to relieve the bowels is useful. 

In cases of chronic joint pains affecting children who are old sufferers 
from rheumatism, it will be often necessary to change the conditions under 
which the patient has been living. Bemoval to a warm dry air will often 
do wonders. Great attention should be paid to the action of the skin and 
kidneys. Five or six grains of bicarbonate of potash, with an equal quan- 
tity of citrate of iron, given three times a day, will be found of service. 
Fermentable matters and acid-making articles of diet should be taken with 
moderation. 



CHAPTEK IV. 

SPONTANEOUS GANGRENE. 

Amongst the non-infectious general diseases may be included the curious 
condition in which apparently spontaneous gangrene becomes developed 
in various parts of the body. The lesions are often symmetrical, but are 
not so in every case. Sometimes the lower limbs are the parts affected ; 
but portions of the face and trunk may be also attacked. Children, the 
subjects of this tendency, are not always cachectic or otherwise enfeebled ; 
although in many cases the gangrenous process occurs in convalescents 
from acute or depressing disease. After measles a special disposition to 
gangrene is occasionally discovered. The same tendency is displayed, but 
less frequently, after other acute specific diseases, as scarlatina, variola, 
varicella, and enteric fever ; and insanitary conditions generally, combined 
with poor food, have been cited as predisposing causes of the gangrenous 
lesions. It is said to be more common in cold than in warm weather ; and 
some observers are disposed to look upon a low temperature of the air as 
one of the causes of the mischief. 

In the case where the disease appears in a well-nourished child who has 
not previously been subject to any enfeebling influence, the etiology of the 
lesion is obscure. Kaynaud, who was the first to describe a " symmetrical 
gangrene of the extremities," attributes the affection to a spasm of the ar- 
terioles, followed by a migration of blood-corpuscles and transudation into 
the skin. He states that he has noticed, with the ophthalmoscope, spasm 
of the arterioles of the fundus occuli in these cases. The disease is some- 
times associated with intermittent hematuria ; and Dr. Gee has reported 
the case of a little girl, aged five j^ears, in whom gangrene of the vulva was 
combined with embolism of the kidney and the brain. Still, in many cases 
no lesion of the viscera or arterial system is discoverable on the closest in- 
vestigation ; and no evidence has yet been brought forward pointing to 
any centric or nervous defect capable of exciting mortification of the tis- 
sues, although the symmetrical distribution of the lesions is suggestive in 
many cases of some such mode of origin. Dr. Nedopil, in explaining the 
mechanism by which spontaneous gangrene is produced, assumes the ex- 
istence of a functional nervous derangement. This writer agrees with 
Baynaud in ascribing the arrest of circulation to a spasm of the walls of 
the arterioles in the part affected. He supposes that owing to irritation of 
sensory and centripetal nerves the reflex centre of the vaso-constrictors 
which control the circulation at the extremities of the limbs is excited. If 
the spasm be prolonged and be sufficiently intense to close the arterial 
channels, gangrene of the part may be induced. 

Children of all ages may suffer from the disease. It may occur imme- 
diately after birth, or may appear in later childhood. It is not always 
fatal ; but if the gangrene is extensive and penetrates deeply through the 
skin, it seldom terminates otherwise than unfavourably. 



SPONTANEOUS GANGKENE — MORBID ANATOMY — SYMPTOMS. 167 

Gangrene as it affects the mouth and the lung is described elsewhere. 
In the present chapter gangrene of the skin and underlying tissues will 
alone be considered. 

Morbid Anatomy. — Gangrene may affect the healthy skin or may attack 
a blistered surface. In the first case the skin becomes dark blue in colour, 
and then almost black. Its consistence varies. Sometimes it is hardened 
and feels dry like parchment ; in others it is softer and moist. At the mar- 
gins of the gangrenous patch the skin is reddened and inflamed. Instead 
of blackened patches the gangrene may assume the form of ulcers limited 
in extent. These ulcers are circular in shape, with abrupt, clean-cut edges, 
and their depressed floor is formed of a gray or blackish slough. They 
may penetrate completely through the skin. 

When gangrene attacks a blistered surface the lesion is usually more 
superficial than in the former case. It appears in the form of a lightish 
gray slough, marbled here and there with a violet tint. 

Sometimes the gangrene penetrates completely through the skin and 
subcutaneous tissues. It may then be found in two forms : a moist and a 
dry variety. In the moist form the gangrenous patch is black, softened, 
and infiltrated with a dirty, reddish fluid. Its odour is excessively offensive, 
and the tissues affected appear to be completely converted into a putres- 
cent pulp. Often it begins as a small pimple, which changes into a bleb 
containing thin purulent matter. As the process continues, more and 
more skin becomes involved, and a considerable extent of surface may be 
reel, cedematous, and boggy to the touch. The centre is usually purple. 
On this surface blebs form and burst, leaving spots of gangrene. The 
sloughs unite, and if the patient survive may become limited. The gan- 
grenous part is then thrown off, leaving the under muscles exposed. 

When the gangrene assumes the dry form its anatomical characters are 
similar to those of senile gangrene. MM. Rilliet and Barthez describe a 
case in which the skin of one leg was completely mortified. On the toes 
it was shrivelled and blackish. Elsewhere it was transparent, hard, red- 
dish, and elastic like a piece of parchment. The dried skin was so trans- 
parent that the injected venous radicles could be seen ramifying on the 
under surface, and it had a curious resemblance to the rind of bacon. 

In some cases ante-mortem clots have been found in the arteries lead- 
ing to the affected part ; but in not a few cases no embolus is to be found 
in the femoral or other arteries of the diseased limb. 

A common seat for this spontaneous gangrene is the vulva in the fe- 
male child. Here the gangrene usually begins on the labia, and may 
spread thence to the interior of the vulva, to the anus and the sacrum. The 
affected parts are dry and blackish-brown, and may slough off, leaving the 
muscles exposed. In male infants the scrotum is sometimes attacked. 
Often the patches of gangrene are not limited to one region or to one 
limb, but occur in scattered spots of various sizes situated on the legs, 
the arms, the buttocks, or other parts of the body. The lesions are then 
often symmetrical, attacking corresponding parts of the surface on the two 
sides. 

Symptoms. — Children the subjects of this tendency to spontaneous 
mortification are liable to attacks of what has been called "local asphyxia." 
Some part of the body — usually a finger, a toe, or the whole of a hand, a 
foot, or even a limb — becomes excessively painful, and is noticed to be 
purple in colour. It feels cold to the touch. The tint may deepen to a 
dull leaden hue. After three or four hours, during which the greatest 
anxiety has been excited, the pain subsides ; the colour of the part grows 



168 DISEASE IN CHILDEEN. 

lighter and then becomes normal, and the natural warmth returns to the 
skin. These attacks are sometimes accompanied by severe abdominal 
pain. Occasionally, too, they are followed by hematuria of a distinctly 
intermittent character, the water being normal at some times, red with 
blood at others. The attacks of local asphyxia do not always subside 
harmlessly. In some cases the symptoms grow slowly worse, and the af- 
fected part becomes gangrenous. 

Gangrene occurs in two principal forms : disseminated and more or 
less symmetrical gangrene, and gangrene limited to the extremities, the 
vulva, or the scrotum. 

In the disseminated variety the disease begins in scattered nodules or 
patches. The child for some days appears to be unusually drowsy, and 
then, if old enough to speak, complains of pain in some part of the body — 
the thighs, legs, buttocks, or arms— and livid patches make their appear- 
ance, which grow rapidly darker in colour. The patches are hard and 
tough to the touch, and seem to be tender, for pressure elicits signs of 
suffering. If the patches are few and small, the general health may be 
little affected ; but if they are large or numerous, there may be vomiting, 
headache, and general malaise. 

Dr. Southey has reported the case of a little girl, two and half years of 
age, who had a feverish attack accompanied by purpuric spots on the 
limbs. She soon recovered, but some months afterwards had a second at- 
tack which lasted three days. About a fortnight later the child complained 
of headache, and said she had hurt her legs. The pain was increased by 
friction of the limbs. In rubbing them it was noticed that the skin on 
the backs of the calves was livid. Soon afterwards the child vomited, com- 
plained of headache, and was feverish. Towards the evening the patches 
were seen to have extended up and down the calves and to be darker in 
colour. A similar appearance was noticed at the backs of the arms, and 
on the following morning the buttocks had become livid. 

When admitted into the hospital on the second day the child was mori- 
bund. The pulse at the wrist was feeble and somewhat wiry, but could 
still be counted. The tibial pulse could not be detected. The patches of 
lividity felt hard and tough. The lungs and heart appeared to be quite 
healthy. Brandy and milk were given, and two doses of nitro-glycerine, 
but all were vomited. Intelligence was preserved until evening. Convul- 
sions then occurred, and were frequently repeated until the child's death at 
11 p.m. The illness altogether lasted only thirty-two hours. A post- 
mortem examination of the body discovered no coarse lesion of the viscera, 
nor could any embolus be detected in the femoral or other arteries of the 
left lower limb, which was the only one examined. 

Mr. Astley Bloxam has kindly communicated to me the particulars of a 
case of spontaneous gangrene which was under his care in the Charing 
Cross Hospital. The child — a little girl of ten months old — had been ail- 
ing for eight weeks. A small pimple then appeared on the region of the 
inferior angle of the scapula. The next day a head formed on the pimple, 
and became filled with purulent fluid. When the child was admitted a 
day or two afterwards (on August 19th) she was seen to be pale and thin, 
and was said to be wasting. The whole of the scapular region on the right 
side was oedematous, red, boggy, and hot. In the centre was a purpuric 
patch an inch and a half long by three-quarters of an inch broad, the bor- 
ders of which were quite purple. On palpation the patch gave a boggy 
sensation to the finger, as if from fluid underneath the skin. The tempera- 
ture on the first evening was 101.8°. 



SPONTANEOUS GANGKENE— -VAEIETIES. 169 

On August 20th the patch had slightly enlarged. Temperature : in the 
morning, 100.6°; in the evening, 101.2°. Pulse, 96 ; respirations, 60. 

On August 21st the patch was much larger, measuring three and three- 
quarter inches long by two and one-half inches broad. Some bullae had 
appeared on the surface, and one of these had burst, leaving a small slough. 
There was no tenderness at the gangrenous part ; indeed the opposite 
appeared to be the case, and the part seemed to be unusually devoid of sen- 
sibility. Temperature : in the morning, 98°; in the evening, 99.6°. Pulse, 
120 ; respirations, 60. An ammonia and bark mixture was ordered, and in 
the evening the part was well painted with strong nitric acid. The applica- 
tion caused no pain. Thirty drops of brandy were ordered every three 
hours. 

After this the slough did not further increase. On the contrary, it be- 
gan to separate, and the surrounding oedema to subside. There was a little 
diarrhoea. On August 21th part of the slough came away and exposed the 
muscles. The child became very fretful and weak, and died rather sud- 
denly on August 29th. 

When the gangrene attacks the extremities, it may be seen in the fingers 
and toes, or may spread to the hands and feet, or even higher up in the 
limb. Children so affected are usually pale, under-nourished, and cachectic 
in appearance. After a few days of more or less irritability, loss of appetite, 
headache, sleepiness, and general malaise, the patient begins to complain 
of severe pains in the toes, which may extend for some distance up the legs. 
At the same time the ends of the toes are noticed to be dull red or purple, 
and their sensibility is found to be blunted. The pains continue. There 
may be some fever at night, and in the morning the lividity of the ends of 
the toes is seen to have extended to the circumference of the nail. At this 
point the symptoms may subside, the pains becoming moderate, and the 
lividity fading and disappearing ; or, on the contrary, the disease may go 
on to complete sphacelus, and extend to the whole of the foot or even of 
the lirnb. Thus, Francois records the case of a child, three years of age, 
in whom the gangrene involved the whole of the foot and lower part of the 

lpcr 

This form of gangrene may be dry or moist. If the former, it assumes 
the characters of senile gangrene, becoming separated by a Hue of demar- 
cation, and subsequently detached. Raynaud reports the case of a little 
girl, aged eight years, of good constitution and healthy appearance, who 
began to complain of severe pains in the feet and lower halves of the legs. 
At the same time the ends of the toes were noticed to be blue. The pains 
increased and the child was a little feverish. The fourth toe on each foot 
became slate-coloured, and the other toes showed spots of livid red. The 
mortified parts were insensible to the touch, but the pains continued and 
were worse at night. The appetite remained good, and there was no diar- 
rhoea. After a few days the pains ceased, and the gangrenous patches be- 
came limited by a well-defined line. In about a fortnight the toes desqua- 
mated. Dry brown scabs became detached, and left the skin beneath them 
tinted of a pale violet colour. On the fourth toe of the right foot, the one 
which had exhibited the largest patch of gangrene, a black crust was thrown 
off, and a suppurating surface was left which quickly healed. 

A very similar case has been published by Dr. Southey. In this the 
spots of gangrene were accompanied by subcutaneous mottlings of the 
trunk and limbs. These mottlings developed into a raised rash like ery- 
thema tuberculatum. The eruption at first itched, then became tender 
and painful, but eventually subsided, leaving merely a discolouration of the 



170 DISEASE IN CHILDREN. 

skin. Recovery in such cases is sometimes followed by an attack of par- 
oxysmal hematuria, in which large quantities of crystals of oxalate of lime 
are passed with the urine. 

In the moist gangrene of the extremities the affected part — which is 
commonly the end of a finger or toe — is swollen, and the epidermis is raised 
up by red serous effusion. As the destruction of the tissues of the part 
proceeds, the articulation may be laid open. Sometimes moist gangrene 
of the extremities is combined with disseminated spots of a kind similar 
to those previously described. Thus, MM. Rilliet and Barthez refer to the 
case of a little girl, aged four years, who was under the care of Legendre. 
In this child moist gangrene attacked the ungual phalanges of the right 
thumb and middle finger — in the latter laying open the second articulation 
— and the ungual phalanx of the left forefinger. Moreover, gangrenous 
blebs filled with bloody serum formed at the back of the shoulder, in the 
lower part of the dorsal region, and in other parts of the body. At last a 
double pneumonia declared itself, and the child died on the ninth day 
from the beginning of the illness. 

When the gangrenous process attacks the vulva, the lesion is usually 
seen in a cachectic or weakly child, who has lately passed through an ex- 
hausting illness. Severe measles occurring in a scrofulous subject is some- 
times followed by this dangerous sequela. As in gangrene of other parts 
the earliest symptoms are usually loss of appetite, headache, and nausea. 
Then the child complains of severe burning pains in the genitals ; and a 
light red circumscribed patch is seen on one of the labia, often on its inter- 
nal aspect. Arcund it the tissues are dense and swollen for some distance. 
The patient cries frequently with the pain, and seems to suffer great dis- 
tress in passing her water. After a day or two ashy gray spots appear. 
These are circumscribed and limited by a light red ring. Soon their 
colour changes to a dark brown or black, and the gangrene spreads to the 
upper part of the vulva, the perinasum, and the anus. Often there is a 
purulent, offensive discharge from the diseased surface. The general symp- 
toms also become more pronounced. The pulse is small and rapid ; the 
features are pinched, and the face is very pale. The child lies moaning in 
her bed, and complains of pains not only in the diseased parts, but also in 
the limbs and body. Sometimes a watery diarrhoea comes on, and in that 
case the child soon dies exhausted. If by energetic treatment the gan- 
grenous process can be arrested before it is too late, the sloughs separate, 
the swelling and darkness subside, and a granulating surface is left which 
quickly heals. 

The gangrenous patch is sometimes single and of limited extent. Often 
the case is first seen when the separation has partially occurred, and a 
sloughy-looking ulcer is found on one of the labia. Still, however small 
the local lesion may be, the general symptoms are severe, and on account 
of the exhausted state of the patient the danger is very great. At the be- 
ginning of the disease a slight febrile movement is sometimes noticed, and 
the temperature may reach 100° or 101° ; but the pyrexia usually quickly 
subsides, and the temperature for the remainder of the illness is below 
the level of health. Death in cases of gangrene may occur from exhaus- 
tion. Sometimes it is ushered in by a series of convulsive attacks. In Dr. 
Gee's case of gangrenous ulcer of the vulva an extensive embolism was 
found in the cerebral arteries." 

Diagnosis. — The diagnosis of spontaneous gangrene in the child pre- 
sents little difficulty. The only case in which a mistake is likely to be 
made is that in which the disease attacks the extremities of the fingers or 



SPONTANEOUS GANGRENE — PROGNOSIS — TREATMENT. 171 

toes. In that case the pricking pain, combined with the livid hue of the 
skin, is suggestive of chilblains ; and, indeed, according to Raynaud, 
cases of this variety of gangrene have been often confounded at the begin- 
ning with this common and insignificant disease. In most cases of gan- 
grene, however, the pains are far more severe, the occurrence of the local 
symptoms is more abrupt, and several fingers and toes are attacked simul- 
taneously. Moreover, the gangrenous lesion is often found at a season 
when the common chilblain is not usually suffered from. 

Prognosis. — In every case of gangrene, whatever part of the surface be 
attacked, the prognosis is most unfavourable. The patient, indeed, does not 
always die, but instances of recovery are rare. If the patient be a new- 
born infant, or a child of weakly constitution, he may be considered to 
have still fewer chances of passing safely through so formidable an illness. 
The most favourable cases are those in which the gangrene is of the dry 
variety and remains limited to a finger or toe. If the gangrenous process 
appears successively in several parts of the body, little hope of recovery 
can be entertained. 

Treatment. — In all cases where a cachectic child is attacked with gan- 
grene, every effort should be made to support the strength of the patient, 
and improve the state of his nutrition. He should be supplied with as 
much nourishing food as he can digest. Meat — pounded if necessary, and 
strained through a fine sieve — eggs, milk, well cooked vegetables, and a 
judicious quantity of farinaceous matter must form his diet. Stimulants 
are always required, and the child may take half an ounce of port wine, or 
the St. Eaphael tannin wine, diluted with an equal proportion of water, 
after each quantity of food. 

If the patient be an infant at the breast, we should inquire if the sup- 
ply of milk is adequate to his necessities. If the breast milk is poor and 
insufficient, additional food must be given as directed elsewhere (see page 
603). White wine whey is very suitable in these cases. Tonics are always 
required. Quinine can be given in full doses (two grains for a child of 
three years old, three times a day), or the ammonia and bark mixture can 
be ordered. Mr. Cripps speaks highly of opium given frequently in small 
doses. 

In cases of disseminated moist gangrene the heat of the part should be 
maintained by hot applications ; and directly a slough is noticed on the 
surface its further extension should be prevented by the free application of 
a powerful escharotic. Strong nitric acid should be applied once thor- 
oughly, and the part must be then kept covered with hot poultices. When 
the slough separates, the resulting sore or sores can be dressed with a 
carbolic-acid lotion (five drops to the ounce of water), or a solution of bo- 
racic acid (twenty grains to the ounce). In all cases of gangrene of the 
vulva this method of treatment is useful ; and the local measures employed 
in the treatment of gangrenous stomatitis are equally serviceable when 
the vulva is the part affected. Parrot advocates the use of powder of 
iodoform, especially in cases of gangrene of the vulva. The ulcers must 
be first carefully cleaned. Then they must be completely filled with the 
powder, no part of the raw surface being left uncovered. If the ulcer is 
very moist, it ought to be dressed twice a day. This method of treatment 
is painless, and is said to arrest the progress of the ulcer in three or four 
days. At the same time the surrounding oedema rapidly diminishes. 

When the gangrene is limited to the extremities, the affected part 
should be wrapped in cotton wool, and gentle frictions with a piece of 
flannel moistened with eau-de-Cologne are recommended by Raynaud. This 



172 DISEASE IN CHILDEEN. 

author disapproves of the use of energetic local stimulants, and states 
that he has seen very disastrous results follow quickly upon undue local 
irritation. Directly a line of demarcation forms, hot dry applications, 
such as bags of heated bran or sand, should be kept applied to the seat of 
the lesion, so as to preserve the dryness of the tissues and hasten the 
separation of the sphacelated part. In extensive gangrene amputation has 
been sometimes performed, but without saving the life of the patient. In- 
deed MM. Rilliet and Barthez are of opinion that the removal of the dis- 
eased member only hastens the fatal termination. 



Part 3. 
THE DIATHETIC DISEASES, 



CHAPTER I. 

SCROFULA. 



The scrofulous diathesis is one of the most common of the morbid types 
of constitution which we meet with in the child. It is found in all ranks 
of life, and in almost all parts of the world. It is, however, especially fre- 
quent in the temperate zones, being far less common in very cold or in 
tropical climates. This vice of constitution is often hereditary, and is 
then handed down with singular persistence from generation to genera- 
tion. Sometimes, indeed, it is seen to pass over certain members of a 
family, but even those who escape may not transmit complete immunity to 
their offspring. 

A child who has the misfortune to be born with this unhappy predis- 
position is liable to very widespread evidences of the constitutional fault 
with which he is burdened. His skin, his mucous membranes, his bones, 
joints, organs of special sense, lungs and lymphatic system are all excep- 
tionally sensitive to the ordinary causes of disturbance, and may all or any 
of them become the seat of obstinate derangement or even of incurable dis- 
ease. These manifestations of the constitutional tendency usually take 
place early, so that scrofula is especially a disease of childhood. Infants, 
indeed, are in great measure exempt from its attacks ; but after the third 
year it begins to be common, and from that age until the fourteenth or fif- 
teenth year the diathesis is most active. At puberty its energy sensibly 
abates, and strumous disorders are less and less frequently met with as the 
individual advances towards middle life. 

Causation. — One of the most important of the causes of scrofula is he- 
reditary influence. When the parents are actually suffering from the ca- 
chexia, or have suffered from it, the child is hardly likely to escape a share 
in the constitutional predisposition ; but when no such manifestation of 
the tendency has been seen in the father or mother, there is a hope that 
by careful management and attention to the laws of health the same freedom 
may be extended to their offspring. But besides actual scrofulous disease, 
other debilitating influences in the parents may determine the strumous 
constitution in their children. Thus, the cancerous and tubercular ca- 



174 DISEASE IN CHILDREN. 

chexise will do this. Syphilis in the third generation is apt to manifest 
itself by scrofulous disorders ; and age in the father, or imperfect nutri- 
tion in the mother during her period of gestation, are also held to be deter- 
mining causes of a congenital tendency to strumous complaints. Whether 
mere nearness of relationship on the part of the parents will exercise the 
same influence is a question which has been often debated, and many 
writers hold that it can do so. I do not think, however, there is any satis- 
factory proof that such a result can follow in cases where there is not 
already a tendency to scrofula in the family. 

Besides being hereditary, the diathesis, it is commonly held, may be 
acquired under conditions favourable to its development. It is true that we 
frequently see patients who exhibit all the signs of a scrofulous lesion 
without any discoverable family history of scrofulous disease ; but it is often 
difficult to trace out hereditary taints, especially when the transmitted ten- 
dency has been mild in its manifestations, or has skipped over one or two 
generations. It is more probable that in such cases latent scrofula is 
developed by debilitating influences in children, who, under more favoura- 
ble circumstances, would have escaped altogether. 

The causes which are thus capable of developing the cachexia in chil- 
dren whose constitutional tendency is comparatively feeble, are all the 
various agents which impair the nutrition of the body by weakening diges- 
tion, checking assimilation, and interfering with the escape of waste mat- 
ters from the system. Repeated exposure to cold and damp ; an habit- 
ual coarse and indigestible diet ; absence of fresh air, and confinement to 
close, ill-ventilated rooms ; deprivation of sunlight and want of exercise 
— the continued operation of these causes, if it cannot set up the disease 
where no predisposition exists, has at any rate a powerful influence in 
exciting the cachexia in children who have been born the subjects of the 
diathesis. Even grown up persons exposed to such unhealthy conditions 
are often found to become scrofulous. Therefore causes which are capa- 
ble of reawakening the cachexia in the adult, after the age most prone to 
it has passed by, must act with still greater energy in the child. Certain 
fevers have the power of developing or re-instating the disease in suita- 
ble subjects. Measles and whooping-cough have a wonderful influence in 
this respect. Unmodified small-pox used frequently to be followed by ob- 
stinate scrofulous disorders ; ancl scarlatina can count the same complaints 
amongst its sequela?. Where the predisposition is strong, it is probable 
that any disease of a lowering tendency may suffice to develop it. 

Scrofula, like other complaints, has been said to have been communicated 
by vaccination ; but that the disease possesses any specific morbid matter 
which is capable of being conveyed from one child to another by inocula- 
tion is a doctrine which has now been proved to be destitute of any foun- 
dation. 

Morbid Anatomy. — The structural lesions induced by the scrofulous 
diathesis consist in various chronic inflammations with their consequences. 
These have nothing special in their anatomical characters to distinguish 
them from the same lesions occurring in non-scrofulous children. They 
need not, therefore, be further referred to in this place. 

The affection of the lymphatic glands, which is so characteristic a part of 
the disease, differs from the ordinary hyperplasia induced in a healthy child 
by neighbouring inflammation in the fact that the swelling does not subside 
when the irritant which has given rise to it has passed away, but continues 
as a chronic condition. In the case of a healthy child the gland becomes 
more vascular, and swells up by an increase in its corpuscular elements. 



SCROFULA — MOEBID ANATOMY — SYMPTOMS. 175 

These rapidly increase, multiply, and enlarge, and acquire many nuclei 
which fill their interior. This is the first step. In the second, one of two 
things may take place. If the irritation subsides and cell-production is 
checked btf jre the nutrition of the gland is interfered with, a fatty degen- 
eration takes place in the new cells which reduces them to a milky fluid. 
They are then absorbed and the gland resumes its former size. If, on the 
contrary, the irritation persist, the proliferation of cells continues ; they 
crowd together, destroying the reticulum and the capillar} 7 network of the 
gland, arrest nutrition by their pressure, and lead to rapid disintegration 
and suppuration. This, then, is an active process conducted rapidly. In 
the scrofulous child the course is much more protracted. The glands are 
apt to take on a chronic inflammatory process. They increase slowly in 
size, and remain a long time as indolent lumps, apparently incapable of fur- 
ther change ; or, if the swelling have been originally acute, no diminution 
in size takes place when the inflammatory process is at an end. In either 
case the gland is filled with proliferating cells, which by their pressure 
hinder nutrition, and induce an imperfect fatty degeneration, so that the 
gland is converted either wholly or in part into a mass of cheesy matter. 

Glands so affected have a spongy feel, unless there is much hypertrophy 
of the connective tissue, in which case they become hard. Their section 
is pale red, passing into a dirty white or yellowish colour. After a time the 
whole gland becomes thick, tough, anaemic-looking, and dry, and is then 
quickly converted into an opaque, yellow, caseous mass. Disease in the 
glands is unequally distributed. Some are unaltered, and even of those 
affected there is great variety in the degree to which the process extends, 
for some remain small while others enlarge considerably. After remaining 
for a long time inactive one of two changes may take place. Either the 
gland softens, sets up inflammation around, and evacuates its contents ; 
or the fluid part of the gland is absorbed, and the gland dwindles into a 
fibrous mass, or is hardened by the deposition of earthy salts. The cervi- 
cal glands often suppurate ; the bronchial glands occasionally do so, but in 
the mesenteric glands such a termination is very rare. 

Softening and suppuration constitute a chief danger of caseous glands. 
In the glands of the neck this is of less moment than in those of the closed 
cavities, for their contents are discharged externally, and are thus removed 
from the body. Even in these cases secondary consequences may ensue. 
The existence of a chronic discharging sore, such as often results from the 
suppuration of these glands, is very apt to induce amyloid degeneration 
of the liver, kidney, and spleen. Therefore these organs are frequently 
diseased in scrofulous children. Besides, there is always danger that soften- 
ing cheesy matter may give rise to an explosion of acute tuberculosis ; and 
many scrofulous children fall victims to this fatal disorder. In the case of 
the bronchial and mesenteric glands softening and suppuration are still 
more serious, on account of the effect upon neighbouring organs. This 
subject will be referred to afterwards. 

Symptoms. — In a well-marked example of the scrofulous diathesis the 
constitutional tendency often expresses itself in an unmistakable manner 
in the build and general appearance of the child. He is stout and heavy, 
and looks as a rule older than his age. The subcutaneous fat is usually 
over-developed, and in places remarkably so. His face is broad and fat, 
with a thick upper lip, and a wide nose. The limbs are stout, with thick 
ends to the bones, and the abdomen is inclined to-be large. But although 
the adipose tissue is relatively increased, there is a want of firmness about 
the child's flesh, and his limbs feel soft and flabby. Such children are not 



176 DISEASE m CHILDREN. 

necessarily ill-favoured. The general want of delicacy and refinement in 
the features is often redeemed by the large size and dreamy expression of 
the eye, by the high colour in the cheeks, and by the redness and fulness 
of the lips. 

Such characteristics are, however, seen only in pronounced cases of the 
diathesis, and even then are not always to be found. All the tendencies of 
the scrofulous constitution may be active in a child without his presenting 
any such peculiarities of face or figure. Indeed, in many strumous cases 
the child is seen to have a spare frame, with delicate features and a thin 
transparent skin — a type which conforms more to the tubercular variety of 
constitution to be afterwards described. But whether he be stout and 
coarsely built, or thin and delicately framed, there is one indication of the 
diathetic state which is seldom absent in a strumous subject. This is the 
singular activity of all the epithelial structures. The hair is soft, thick, and 
luxuriant; the eyelashes and eyebrows are well marked ; and in many 
cases there is a remarkable development of fine down covering the ears, 
cheeks, shoulders, and spine. The skin, moreover, is apt to be rough 
and scaly, and the nails grow fast. This peculiarity marks one of the es- 
sential features of the scrofulous diathesis, viz. : a tendency to rapid pro- 
liferation of all the epithelial and cellular elements of the body. 

It has been said that the scrofulous diathesis is not in itself a disease. 
It is a tendency to disease — a tendency to derangements of structure or of 
function which finds expression under suitable conditions in a variety of 
lesions. All these bear a common character, and vary in gravity according 
to the tissue or organ affected. The lesions are inflammatory in their na- 
ture, and are characterized by rapid cell-growth and rapid decay of the 
newly formed elements. They are not distinguished by any special ana- 
tomical characters which stamp them at once as of scrofulous origin. In 
appearance they do not differ from similar derangements occurring in chil- 
dren of a healthy habit of body. Their constitutional origin is shown by 
their tedious course, for if not stopped at once they soon pass into a chronic 
state ; by their sluggish response to treatment ; and by their proneness to 
relapse when apparently cured. The disturbance originates under the in- 
fluence of some trifling and temporarily exciting cause ; and the length of its 
course is often dependent upon the hygienic conditions surrounding the 
child at the time of the attack. If these are satisfactory, the derangement 
may be quickly recovered from, although it readily recurs when a similar 
cause is again in operation. If they are unsatisfactory, as is usually the 
case amongst the poor, the derangement becomes a chronic disorder, and 
increases in severity and obstinacy as the days go by. 

The parts which are prone to suffer in this diathesis are : the mucous 
membranes, the skin, the bones and joints, the organs of special sense, 
and above all the lymphatic glands. In whatever tissue the lesion is 
seated, the neighbouring lymphatic glands are liable to suffer ; and this is 
a fact so generally recognized that amongst the public the term " scrofula " 
is understood to mean simply a chronic enlargement, with tendency to 
suppuration, of the glands. 

The mucous membranes in all strumous children are especially sensitive 
and subject to catarrh. Gastric and intestinal catarrhs are very common ; 
and we find besides, coryza, ophthalmia, catarrhs of the throat, ear, and 
air-passages, and in girls of the vulva. All these, beginning as catarrhs, 
pass quickly into chronic inflammations very difficult of cure. 

The affections of the gastric and intestinal mucous membranes will be 
considered in another place. They do not differ from the same derange- 



SCROFULA — SYMPTOMS. 177 

merits as they occur in healthy subjects except in the fact — and it is a very 
important one — that in scrofulous children such catarrhs are always accom- 
panied by fever. This is seldom the case with healthy children. If 
pyrexia be present with a simple gastric catarrh, it affords a strong pre- 
sumption that the patient is of a scrofulous constitution. Catarrhs of the 
intestine in these children often set up ulceration of the mucous mem- 
brane. This is an obstinate lesion and may lead to serious consequences 
(see Ulceration of the Bowels). 

Catarrhs of the nasal passages leading to ozrena, and even destruction 
of bone, may be seen. Obstinate discharge from the nose in a baby is 
generally of syphilitic origin ; in a child of two and a half years and up- 
wards it is much more commonly due to the scrofulous cachexia. It is 
very obstinate, gives rise to a distressing and perhaps unavoidable habit 
of snuffling, imparts a nasal character to the voice, and leads to cracking 
and excoriation of the upper lip. 

The eyelids and eyes may be affected with tinea tarsi, pustular ophthal- 
mia, and keratitis, with intense lachrymation and photophobia. 

Pharyngeal catarrh is a very common affection. It is also a very im- 
portant one, for it is accompanied by some enlargement of the tonsils, and 
considerable swelling and thickening of the posterior nares and back of 
the fauces. Consequently there is occlusion of the Eustachian tubes and 
deafness. On inspecting the back of the fauces in such cases we find the 
mucous membrane of a deep red colour. It is swollen and velvety, and is 
covered with a thick muco-purulent secretion. The closure of the Eusta- 
chian tube is not due to enlargement of the tonsils, but to the swelling of 
the mucous membrane. Children so affected present a peculiar appear- 
ance. They have a vacant look, hold their mouths half open, and, hearing 
but imperfectly what is said to them, hesitate and are confused when 
spoken to. They are not really wanting in intelligence, but on account of 
their deafness appear to be so. On examination of the ear the tympanum 
is seen to be drawn in, but it retains its translucency, and there is no 
tinnitus. 

Otorrhoea is very often met with in scrofulous children from catarrhal 
inflammation of the meatus. The inflammation may spread to the inner 
ear, in which case perforation of the membrane always takes place. Severe 
primary otitis may also occur as a result of cold or injury, or as a sequence 
of scarlatina, measles, and small-pox. 

Pulmonary catarrhs in strumous subjects may become chronic and give 
rise to winter cough, with emphysema of the lungs and persistent hyper- 
secretion ; or the catarrh may spread to the air-cells, inducing chronic 
catarrhal pneumonia with all its possible consequences. 

Various skin affections occur in subjects of this diathesis, and are gen- 
erally the earliest manifestation of the constitutional tendency. Acute 
eczemas are common, and slight depressing causes may give rise to an 
outbreak of impetiginous or ecthymatous pustules. Little scratches are 
apt to run into festering sores which may be slow to heal. Occasionally 
we find rupia, pemphigus, or lupus, but these are rare in childhood. A 
not uncommon form of affection of the skin is seen in babies and children 
under two years of age. This begins as a small lump — hard, painless, and 
of the size of a pea or a small nut. It is seated in the subcutaneous tissue, 
and the skin over it is at first freely movable and is natural in colour. 
Gradually an adhesion forms between the little mass and the integument. 
The skin gets red, and after a variable time gives way, and the cheesy 
contents of the abscess are evacuated wholly or in part. After discharging 
12 



178 DISEASE IN CHILDKEN. 

for a longer or shorter period, the sore heals ; its hard base becomes ab- 
sorbed ; and a deep cicatrix is left at the site of the abscess. Several of 
these abscesses are usually seen at the same time in various stages of prog- 
ress. They are seated on the arms, legs, or abdominal wall, and run a 
protracted course, passing very slowly through their several stages. They 
seldom occur except in children of pronounced strumous tendencies. 
When seated on parts where the skin is in close contact with the bone, as 
on the fingers, periostitis may be set up with exfoliation of bone ; but 
elsewhere they have no injurious local consequences. 

Disease of the bones and joints is a very common consequence of the 
scrofulous diathesis. These affections enter more particularly into the de- 
partment of the surgeon. Still, there is one form of bone disease which is 
brought so frequently under the notice of the physician that it may be 
properly considered in connection with this subject. This is caries of the 
bodies of the vertebrae, in its early stage, before it has led to curvature of 
the spine. The reason why we so often see such cases is that the pain, 
which is one of the earliest symptoms of the malady, may, by its seat and 
by the cramp-like character it sometimes assumes, give little indication of 
its being generated in the spine. Like the pain of pleuris} r , the pain of ver- 
tebral caries is often referred to a region far distant from the seat of the 
disease. When the atlas and axis are affected, the pain is referred to the 
occipital region. In the case of the lower cervical vertebrae, it is felt in the 
shoulders, down the arms, or even in the upper part of the breastbone. 
If the caries occupy the dorsal spine, the only discomfort complained of 
may be in the sides of the thorax, the middle line of the chest in front, or 
the epigastrium. In disease of the lumbar vertebrae the pain is reflected 
to the pelvis, or to the lower limbs as far as the knees, or even to the feet. 
But wherever the pain is felt, and whatever may be its degree of severity, 
its cause may usually be distinguished by noting the increase to the child's 
discomfort when he moves about, and the relief he experiences when he 
lies down. Sometimes, however, slow cautious movement may be made 
without uneasiness ; for if the spine be braced up and steadied by the sur- 
rounding muscles, the patient may be able to move carefully about with- 
out communicating any jar to the vertebral segments. But movement 
when the child is taken at a disadvantage, with the spinal muscles relaxed, 
is always distressing, and therefore it is important to inquire as to the 
effect of coughing, sneezing, riding in a carriage, or making a false step in 
walking. 

Besides pain, another important indication is obtained by noticing the 
degree of mobility retained by the spinal segments. The child holds his 
back stiffly, and avoids all movements which necessitate bending of the 
spine. Thus, when laid down on his back and told to get up, he does so 
by turning slowly upon his hands and knees, keeping his back straight, 
and then getting carefully on to his feet. If required to pick up a small 
article from the floor, he turns sideways to the object and lowers and raises 
himself by bending and straightening his knees, keeping the spine straight 
and almost erect. Movements such as these are of great value, and in 
doubtful cases the child should be put through a series of exercises, so as 
to test thoroughly the mobility of his vertebral column. He should be re- 
quired to turn round quickly as he walks, to climb a chair, or to touch his 
toes with outstretched fingers while his knees are straight. 

Another important symptom is the attitude assumed by the patient 
when at rest. If there be much disease of the bones, the child will en- 
deavour to relieve the spine by supporting his head or diverting the weight 



SCROFULA — SYMPTOMS— CASEATION" OF GLANDS. 179 

of the body from his back to his arms. Thus the favourite attitude of a 
child whese cervical vertebras are affected is to sit with his elbows on the 
table supporting his head with his hands. In other cases of the disease 
the weight of the body is transmitted through the arms. Mr. Howard 
Marsh, who has devoted much attention to this subject, describes two char- 
acteristic attitudes assumed by a child the subject of caries of the dor- 
sal and lumbar spines. In one of these he places the palms of his hands 
on a chair, and leans over forwards with his arms straight and shoulders 
raised. By this means weight is taken off the spine and transmitted 
through the arms. Another position is equally characteristic. The child 
rests his weight on one toe, with the heel slightly raised and the knee 
flexed, and placing his hand on the middle of the thigh, leans over, so as 
to convey weight from the shoulder down the arm to the limb. 

Attention to the above points will give very valuable information. 
Other symptoms are less trustworthy. Thus tenderness on pressure over 
the spines of the diseased vertebras is sometimes present ; but it is not 
characteristic of caries. Striking with the knuckles down the centre of 
the back is a very fallacious test. In cases of undoubted caries there may 
be no response ; and a child may shrink when the spine is tapped even 
though the bones are sound. In the same way the application of a hot 
sponge to the spine as a test of tenderness is unsatisfactory, and in the 
case of a child little information is to be gained by this means. 

Whenever spinal caries is suspected we should never forget to look for 
iliac or psoas abscess ; for in cases where the ulceration is limited to the 
surface of the bodies of the vertebrae, an abscess may form before any 
curvature can be detected in the spine. 

Caseation of Glands. — One of the most familiar consequences of the 
scrofulous diathesis is a chronic enlargement of the lymphatic glands. In 
all young subjects these glands are liable to enlarge upon slight irritation ; 
but in a healthy constitution the swelling subsides when the cause which 
gave rise to it has passed away. In the child of scrofulous tendencies tke 
cause exciting the morbid process may be so feeble and transient as to 
escape notice. But, the unhealthy action once set up runs a protracted 
course, and the enlargement continues until some further change takes 
place which causes it to disappear. The steps by which the affected gland 
becomes converted into a cheesy mass have already been described. The 
process is a purely local one, and does not necessarily produce any ill 
effect upon the patient. It is evidence, no doubt, of a constitutional ten- 
dency, and as such may excite apprehensions of other and more formida- 
ble manifestations of the diathetic state. Of itself, however, unless the 
swollen glands be so situated as to press injuriously upon parts in the 
neighbourhood, or to threaten by setting up inflammation around to injure 
a vital organ, it is seldom attended with danger. 

The glands most commonly affected are the cervical, the bronchial, and 
the mesenteric. 

Chronic enlargement of the cervical glands is excessively common, on 
account of the many scrofulous lesions to which the head and face are 
liable. But these lesions do not all act with equal energy in promoting 
the glandular swelling. Liflammation of the pharyngeal mucous mem- 
brane is found to produce this result far more frequently and readily than 
an irritant occupying any other part of the head and face. A skin affec- 
tion may exist for a long time without causing enlargement of the glands, 
but a pharyngitis causes them to enlarge very quickly. Chronic glandular 
swellings are seen as round or oval masses, firm to the touch, and usually 



180 DISEASE IN CHILDREN. 

freely movable. The skin over them retains its normal colour and is not 
adherent. They are generally to be seen behind the ear, beneath the 
lower jaw, and sometimes extending down the neck to the collar bone. 
The masses may be formed of single glands ; but more often several of 
these unite and are bound together by thickened and condensed cellular 
tissue. Such swellings may reach the size of a small apple. Usually, 
after a time, tenderness begins to be noticed ; the skin becomes adherent 
and red ; fluctuation is felt ; and eventually the abscess bursts and dis- 
charges its contents externally. Scrofulous abscesses are slow to heal. 
Often a discharging cavity is left from which a thin pus escapes ; or the 
opening enlarges, and we see a sluggish ulcer with thickened undermined 
edges. In bad cases several of these may be seen at the same time at each 
side of the neck. 

Enlarged cervical glands do not always suppurate. Sometimes, after 
remaining a variable time as a chain of indolent swellings, they begin 
gradually to diminish in size and return slowly to their normal dimensions. 

Caseation of the bronchial glands is little less common than the same 
condition in those of the neck. The effect, however, of such disease is 
very different. Swelling of the superficial glands of the neck, although 
unsightly enough, is yet in itself a complaint of comparatively little 
moment. But when the glands of the mediastinum become enlarged, the 
consequences may be serious. The glands are seated at the bifurcation of 
the trachea, behind the upper bone of the sternum, and a little below it. 
They also accompany the bronchi into the interior of the lung. When 
swollen, they must therefore encroach upon neighbouring parts, and may 
produce considerable disturbance by pressing upon the blood-vessels, the 
air-passages, and the nerves of the chest. 

Before describing the symptoms produced by this means, it may be 
remarked that enlargement of the bronchial glands does not necessarily 
imply the existence of chronic lung disease. A child is not to be con- 
sidered consumptive because his mediastinal glands are bigger than they 
ought to be. The term " bronchial phthisis," which has been applied to 
this condition, is very misleading, and was given at a time when all 
chronic changes in the glands were attributed to tubercle. Scrofulous 
children, who are so prone to suffer from pulmonary catarrh, will generally 
be found, on careful examination, to have some swellings of the glands be- 
hind the sternum ; but if no dulness or bronchial breathing can be de- 
tected over either lung, we have no reason to infer the existence of 
pulmonary disease. Like the same affection in the neck, caseation of the 
glands below the trachea is often a purely local process, induced in a scrof- 
ulous child by some passing irritation. It is more serious than a similar 
condition in other parts only because the glands are shut up in a closed 
cavity, in the immediate neighbourhood of large vessels and vital organs, 
which may be affected injuriously by their pressure, or by pathological 
changes occurring in them. 

It is possible that the bronchial glands may be, as most authorities 
hold, occasionally the seat of tubercle, although arguments in favour of 
this view, drawn exclusively from morbid anatomy, are of only secondary 
value. But there is little doubt that the ordinary form of glandular en- 
largement is due to a very different cause. It is true that children who 
suffer from this form of scrofula are frequently feverish, and that they are 
often thin and under-nourished ; but these phenomena are not necessarily 
the result, of tubercle. It will be generally found that the pyrexia is not 
a constant feature in the case. It occurs now and again, the child's tern- 



SCROFULA — CASEATION OF GLANDS. 181 

perature in the interval being normal, and lasts on each occasion for a 
week or ten days. While the feverishness continues, the child is languid 
and mopes, eats little or nothing, and is generally troubled with cough. 
The explanation is that a child suffering from this cachexia is excessively 
sensitive to changes of temperature and readily takes cold. While the 
catarrh lasts he is feverish ; and as all the mucous membranes are equally 
sensitive, the stomach sympathizes in the general derangement. For the 
time, then, nutrition is in abeyance, and he loses flesh. Even when the 
attack is at an end, and appetite returns, the stomach does not all at once 
recover its power. The patient's digestion continues weak and cannot 
fully satisfy the requirements of his system, so that he regains flesh but 
slowly. If the catarrhs recur at short intervals, the child is kept thin and 
weak ; but he is not therefore tubercular, and if he die, he dies usually 
from a simple bronchitis or pneumonia, and not from any tubercular com- 
plaint. But such children, if in a position to receive all the care they re- 
quire, seldom do die. In my experience such a termination is rare in cases 
where the lungs are unaffected. When due precautions are taken, they 
often become fat and strong, and the signs of glandular enlargement dis- 
appear. 

In many cases the disease in the glands is associated with pulmonary 
phthisis ; but this is more often than not of the non-tubercular variety. 
When death takes place in such cases it results from the lung disease, and 
the glandular swelling contributes little, if at all, to the fatal issue. Death, 
however, does sometimes occur as a consequence of the scrofulous swell- 
ing. The mass may cause such disturbance by pressure upon neighbour- 
ing parts that inflammation and ulceration are set up, and the child sinks 
from exhaustion. Thus the oesophagus or an air-tube may be perforated, 
as in a case published by Dr. Gee, without any softening having occurred 
in the gland. In other cases the gland softens and becomes converted into 
a mass of pus. Here there is hectic fever, general and persistent wast- 
ing, and loss of strength. Eventually the abscess discharges itself into the 
pleural cavity, into a bronchus, or into a large vessel, causing fatal hsemor- 
rhage. A common termination when softening takes place in the gland is 
by acute tuberculosis. This, however, may occur in the case of any other 
softening cheesy mass wherever situated. It is no proof that the gland 
was originally the seat of tubercle. 

The special symptoms produced by enlargement of the mediastinal 
glands are the consequence of pressure — the glands by their unwonted size 
encroaching upon the parts around. 

Pressure upon the superior vena cava, or either innominate vein, inter- 
feres with the return of blood to the heart. There is a certain degree of 
lividity of the face, the skin around the mouth has a bluish tint, and the 
lips look puffy and dark. The superficial veins also are unusually visible 
in the temples, the neck, and over the front of the chest and shoulders. A 
small amount of pressure is sufficient in children to cause dilatation of the 
venous radicles of the chest, and the symptom is one of the earliest indi- 
cations that the bronchial glands are larger than they ought to be. If 
there be great obstruction to the return of blood from the head, oedema 
of the face and pumness of the eyelids may be seen ; and this, when one 
innominate vein only is pressed upon, is limited to one side of the face. 
On account of the congestion of the venous system, epistaxis is common, 
and haemorrhage may even occur from the lungs. But hemoptysis in chil- 
dren is difficult to detect, for blood coming up from the air-tubes is al- 
most invariably swallowed, while a discharge of blood from the mouth is 



182 DISEASE IN CHILDEEN. 

usually the consequence of epistaxis, the blood escaping backwards into 
the throat from the posterior Dares. 

Pressure on the nerves of the chest causes hoarseness of the voice and 
paroxysmal cough which may be mistaken for whooping-cough. It occurs 
in violent fits, and sometimes ends in a crowing inspiration. It is, how- 
ever, seldom followed by vomiting. When the pressure affects also the 
lower end of the trachea at its bifurcation there may be, in addition, attacks 
of dyspnoea. These are the ordinary " asthmatic attacks " of young children. 
Sometimes laryngeal spasm is induced, and long-continued spasm may so 
interfere with the entrance of air into the lungs that the antero-posterior 
diameter of the chest becomes diminished, the weight of the atmosphere 
forcing the sternum backwards below the level of the ribs. All these press- 
ure symptoms become greatly aggravated by an attack of pulmonary ca- 
tarrh. In ordinary cases severe symptoms are only seen when the child 
catches cold. If this happen, the condition of the patient becomes alarm- 
ing. His face is livid ; his dyspnoea distressing ; his voice hoarse ; his 
cough violent and spasmodic. Even then the attack is often not continu- 
ous. It occurs in sudden seizures which come on once, or more often, in 
the day, or only at night. The attacks last a variable time and create 
much alarm. In most instances their violence abates after a few days, 
and in the course of a week or so the child seems restored to his ordinary 
health, although he is left languid and more feeble than before his illness. 
In other cases the symptoms increase in severity instead of diminishing. 
The child starts up suddenly in his bed with staring eyes and a dusky, 
frightened face ; his respiratory muscles work violently, and his agitation 
and distress are painful to see. After several repetitions of these attacks 
death may take place either suddenly, or after a fit of convulsions. 

The physical signs afforded by examination of the chest are of impor- 
tance. In marked cases we find dulness on the first bone of the sternum, 
which may extend for some distance on each side and below. Sometimes 
it is found to reach as far downwards as the base of the heart. I have 
never succeeded in detecting any dulness in the back between the scapulae. 
Indeed, the results of percussion even in front are often misleading. There 
may be very considerable and extensive disease in the glands, and unless 
the mass is in actual contact with the wall of the chest no dulness may be 
discovered at the spot. The signs afforded by the stethoscope are much 
more trustworthy. Pressure upon the lower part of the trachea produces 
a respiratory stridor which is sometimes so loud as to be heard at a distance 
from the chest. It is generally intermittent. In either bronchus marked 
pressure may interfere with the entrance of air into the corresponding lung, 
and lead to a certain amount of collapse at the base. Pressure such as this, 
however, is exceptional, and is only seen in cases where the enlargement is 
great. The most common auscultatory sign connected with the breathing 
is produced by conduction, the glands forming an artificial medium of 
communication by which sound is conveyed from the air-tubes to the chest 
wall. This gives to the breathing a loud blowing character which is very 
characteristic. It is less high pitched and metallic than the ordinary blow- 
ing and cavernous breathing heard in cases of pulmonary consolidation and 
excavation ; and is most marked at the apices of the lung, especially at the 
supra-spinous fossae. Sometimes it is heard loudly over the whole of one 
or both sides of the chest. Opening the mouth generally modifies consid- 
erably the intensity of this blowing quality, and may even make it cease 
altogether. 

Pressure upon the descending vena cava or the left innominate vein 



SCROFULA — SYMPTOMS — CASEATION OF GLANDS. 183 

gives rise to a hum, and on the pulmonary artery to a systolic murmur 
heard best at the second left interspace. But long before the ordinary 
signs of pressure on the vessels can be detected, we can induce pressure 
on the vein if the bronchial glands are enlarged. This sign is one of the 
earliest indications of disease in these glands. 1 Thus, if the child be di- 
rected to bend his head backwards upon his shoulders so that his face is 
turned upwards to the ceiling above him, a venous hum, which varies in 
intensity according to the size and position of the swollen glands, may be 
heard with the stethoscope placed upon the upper bone of the sternum. 
As the chin is slowly depressed again the hum becomes less distinctly audi- 
ble, and ceases shortly before the head reaches its ordinary position. The 
explanation of this phenomenon appears to be that the retraction of the 
head tilts forward the lower end of the trachea. This carries with it the 
glands lying in its bifurcation, and the left innominate vein is compressed 
where it passes behind the first bone of the sternum. I believe this ex- 
planation to be the correct one, for in cases of merely flat chest, where there 
is no reason to suspect enlargement of the glands, the experiment fails. 
Nor, again, can the hum be produced in a healthy child by the thymus 
gland. This gland lies in front of the vein immediately behind the sternum. 
Enlarged bronchial glands lie behind the vessels in the bifurcation of the 
trachea. A swelling in front of the vessels does not appear to be able to 
set up pressure upon the vein when the head is bent backwards in the 
position described. Again, in order that the experiment should succeed, 
the lower end of the trachea must not be fixed, and the glands lying below 
its bifurcation must be movable, otherwise no hum is heard when the head 
is retracted. Thus a child was admitted into the East London Children's 
Hospital for lymphadenoma. There was dulness at the upper part of the 
sternum, and downwards as far as the base of the heart. In this case, to 
my great surprise, no venous hum could be heard. The child died, and 
on examination of the body, yellow, flattened, cheesy masses were found 
adherent to the inner side of the sternum, and others, very large and im- 
movable, were seen filling up the interval between the bifurcations of the 
trachea. The lower end of the air-tube was held firmly down by the mass, 
consequently pressure could not be brought to bear upon the vein by bend- 
ing of the head, as the glands, being fixed, could not be brought forwards 
against the vessel. The experiment may sometimes fail even in cases where 
the lower end of the trachea with its caseous glands is free to move, for the 
relative position of the glands and the vein may not correspond ; but as a 
rule it will succeed, and a venous hum, so induced, is, I believe, a certain 
sign that the glands of the mediastinum are not healthy. 

The mesenteric glands are, perhaps, less commonly affected than those 
of the neck or the chest ; but disease in them is far from rare, although it 
cannot always be detected during life. The affected glands may be sepa- 
rate, or they may unite as in other situations into masses bound together 
by thickened cellular tissue. In this way a mass the size of an apple ; and 
more or less movable may be felt on manipulation of the abdomen. 

The old name for disease of the mesenteric glands was tabes mesen- 
terica, and very serious consequences were described as resulting from the 
glandular enlargement. It is now known that these symptoms are due, 
not to the mesenteric swellings, but to the lesion of which they are the con- 
sequence ; and that the caseous glands form a part — and often only a very 

1 See a paper by the writer, " On the Early Diagnosis of Enlarged Bronchial Glands." 
Lancet, August 14, 1875. 



184 DISEASE IN CHILDREN. 

insignificant part — of the disease from which the patient is suffering. Like 
the lymphatic glands in other situations, those of the mesentery swell up 
as a result of irritation or inflammation in the parts from which the lym- 
phatic vessels passing through them take their origin. In strumous sub- 
jects they have the same proneness as the others to become caseous. Of 
themselves they form a strong argument against the tubercular theory of 
scrofulous glandular enlargement ; for caseation of the mesenteric glands, 
unless their size be such that they press upon neighbouring parts, is in 
itself a by no means serious matter. In ordinary cases, where there is 
no accompanying lesion of the bowels, the child's nutrition is good ; his 
spirits and appetite are satisfactory ; his temperature is normal ; and ex- 
cept, perhaps, for some slight pallor of face, he may show no sign of ill- 
health. In most cases, however, swelling of the glands, if at all considera- 
ble, is combined with scrofulous ulceration of the bowels ; but even here 
the consequences are not always as serious as might be expected. Much 
depends upon whether or not the ulceration of the intestine is accompanied 
by a catarrhal condition of the mucous membrane. If this be present, 
there is diarrhoea with marked disturbance of nutrition. The child grows 
thinner, paler, and weaker ; his expression is distressed ; he sleeps badly at 
night, often asking for drink, and is disturbed by wandering abdominal 
pains. The temperature may rise slightly in the evening, but there is 
seldom marked pyrexia. 

If there be no intestinal catarrh, the bowels may be confined, and the 
effect upon the child's general health is much less pronounced. He still 
looks ill, is troubled by flatulent pains, and is pale and weakly ; but nu- 
trition may be fairly performed, and the child may even appear stout, 
although to the touch his limbs feel soft and flabby (see Ulceration of 
Bowels) . 

When caseation of the glands is associated with tubercular peritonitis 
— and it is to this combination that all old descriptions of tabes mesenterica 
apply — the symptoms are those of the peritoneal disease, and the case is a 
very serious one. 

Scrofulous mesenteric glands are not always easy to detect. The belly 
is so often distended in children, with flatulent accumulations, that it may 
be difficult to force the parietes sufficiently inwards to reach the swollen 
bodies. Moreover, a certain tension of the abdominal wall, more or less 
voluntary, may still further increase the difficulty. The enlarged glands 
lie about the middle of the abdomen, in front of the spine. If the mass be 
a large one, pressing the abdominal wall directly inwards will usually de- 
tect the swelling at once. In cases where the increase in size of the glands 
is inconsiderable, it is better to make pressure laterally, bringing the hands 
together from the sides towards the centre, so as to catch the little mass 
between the fingers. 

If the glands are large enough to press upon the parts around, there 
may be oedema of the legs and scrotum from pressure upon the vena cava. 
This, however, is exceptional. A very small amount of pressure will be 
sufficient to cause dilatation of the superficial veins of the abdominal wall ; 
and most cases of enlarged mesenteric glands are accompanied by this 
phenomenon. Cramps in the legs are said to be sometimes caused by 
pressure upon the nerves of the abdomen ; and ascites may be the conse- 
quence of pressure upon the portal vein by the glands occupying the 
hepatic notch. 

The usual termination of scrofulous glands in the abdomen is that by 
shrinking and petrifaction. They rarely soften, although cases are re- 



SCEOFULA— SYMPTOMS— DIAGNOSIS. 1S5 

corded in which suppurating glands have become adherent to a coil of 
intestine and have discharged their contents into the bowel. 

From the preceding description it will be seen that the phenomena 
produced by the development of the scrofulous cachexia are very numer- 
ous. The manifestations of the diathesis must therefore vary greatly in 
different cases, the constitutional tendency expressing itself now in one 
way, now in another ; for in addition to the general predisposition, the child 
seems also to inherit a special weakness of particular tissues. Thus, in one 
family we see child after child suffer from scrofulous inflammation of the 
eye ; in another there is equal susceptibility of the pharyngeal or the nasal 
mucous membranes ; in a third we detect a special proneness to disease of 
the bones or of the joints. All these disorders are apt to run a tedious 
course and to resist treatment with singular obstinacy. They can only be 
attacked successfully by using means which improve nutrition, and weaken 
the morbid tendency on which the lesion depends. Until this be done 
mere local applications will be of small value. 

Diagnosis. — It has been said that scrofulous lesions have no special 
characters which indicate their constitutional origin. Their real nature 
must therefore be inferred from their lingering course, their tendency 
to recur, the frequent absence of any discoverable local cause to account 
for them, and the coexistence of other disorders of a like nature, espe- 
cially of glandular enlargements. 

The subcutaneous abscesses may be, and often are, mistaken for syph- 
ilitic gummata. They must be distinguished by the history of the case, 
noting the complete absence from it of any syphilitic symptoms. 

The diagnosis of the early stage of spinal caries has been already indi- 
cated in the description of that disease. Kemembering how the pain radi- 
ates in this affection to distant parts, we should always look with suspicion 
upon pain in the chest or stomach in a child of scrofulous tendencies until 
the spine has been tested for the effect of sudden jars or shocks, and the 
child's attitudes as he walks or plays have been inquired into. Persistent 
pain in the occipital region, if combined with any stiffness in the neck or 
any altered manner of holding the head, is always suspicious of caries of 
the cervical vertebrae. Pain in the chest or stomach, unaffected by food 
but increased by movement and relieved by lying down, is highly sugges- 
tive of dorsal caries. In all cases where spinal disease is suspected the 
child should be made to raise himself from a recumbent position, to pick 
up a small object from the floor, or to climb on to a chair or table, and 
his manner of performing these acts should be carefully observed, noting 
the degree of movability of the spine, and whether any part of it is held 
rigid. 

In the case of enlarged glands we may consider that a gland has be- 
come cheesy if it have enlarged without evident cause, and if it persist for 
a long time as a painless indolent tumour showing no tendency to subside. 

Caseation of the bronchial glands may be detected in their early stage 
by the experiment of listening over the upper bone of the sternum while 
the child's head is retracted, as already described. Durness at the upper 
part of the sternum, if combined with any sign of pressure, is very sus- 
picious, especially if there be fulness of the superficial veins of the neck, 
side of the head, and temples. Spasmodic breathing and paroxysmal cough 
are also characteristic symptoms — the more so if they are combined with 
any altered quality of voice. In all cases where children have attacks of so- 
called " asthma," attention should be always directed to the bronchial 
glands (see page 182). 



186 DISEASE IN CHILDBED. 

In the case of the mesenteric glands the only satisfactory proof of their 
enlargement is holding them between the fingers. Even in these cases, 
however, we have to satisfy ourselves that the substance is really a gland, 
and not a cheesy mass attached to the omentum, or a lump of hardened 
feces. Cheesy omental masses are much more superficial, and consequently 
more easily felt than enlarged glands. They are also more freely mova- 
ble. In feeling for mesenteric glands the fingers have to be pressed 
down firmly towards the spine, and the glands, if enlarged, can be detected 
as slightly movable lumps with ill-defined margin. 

The sensation conveyed to the fingers by faecal masses is very different 
to that furnished by enlarged glands. Faecal accumulations can be readily 
studied in cases of typhoid fever where there is no diarrhoea, and the child 
is taking milk. Here we find elongated masses of moderate size lying 
with their long axes in the direction of the bowel, and situated at some 
point in the course of the colon. They are never very deeply placed, and 
can be always readily reached by slight depression of the abdominal wall. 
By firm pressure they can be indented by the finger. If any doubt is felt 
in such a case, the effect of a copious enema should be tried. Faecal masses 
are readily removed by this means ; while lumps due to any other cause 
are only made more evident by the injection ; for this by removing gaseous 
distention and faecal matters, renders a full exploration of the abdominal 
cavity more easy than before. 

Prognosis. — It is the exception for scrofulous children to die from the 
direct effects of the disease. In fatal cases death usually results from 
acute tuberculosis ; the outbreak of the tubercular malady being deter- 
mined by some mysterious process of infection through softening cheesy 
matter or slowly ulcerating bone. Again, children the subjects of this 
diathesis are more sensitive to the ordinary causes of disease. They catch 
cold very readily, and therefore are apt to suffer from various chest affec- 
tions. These, besides their own special dangers, may lead to evil conse- 
quences by causing enlargement and caseation of the bronchial glands. 
Pneumonia, again, has a risk of its own in its propensity to undergo only 
partial absorption, and so to induce chronic changes in the lung. 

Scrofulous children are singularly susceptible to the influence of conta- 
gion. Few such children exposed to the infective principle of zymotic dis- 
ease will be found to escape, unless protected by a previous attack. Such 
diseases, too, have a special power of intensifying the diathetic taint. They 
leave the child not only depressed by his late illness, but also more exposed 
than before to suffer from the consequences of his constitutional weakness. 

Enlarged bronchial glands, if sufficiently advanced to cause serious pres- 
sure upon parts around, must always occasion anxiety. If there be lividity 
of face or attacks of dyspnoea, a very guarded prognosis should be given. 
Still, when placed under favourable conditions such children often do well. 

Enlarged mesenteric glands, if unaccompanied by ulceration of bowels 
or signs of tubercular peritonitis, are in themselves of little importance. 
If signs of intestinal ulceration be present, the case is more serious, and 
the prognosis depends upon the amount of diarrhoea, the presence of dis- 
ease in other organs, and the effect of the lesion upon the nutrition of the 
patient. This subject is considered in another place (see page 665). 

Amyloid disease of organs set up by chronic suppuration is of moment, 
as tending to induce anaemia and lower the strength. Still, in childhood, 
if the primary suppuration be arrested and the scrofulous disease removed, 
the amyloid degeneration often undergoes a surprising improvement (see 
" Amyloid Liver "). 



SCKOFULA — TKEATMENT. 187 

Treatment. — The constitutional tendency to scrofulous lesions is best 
attacked by measures which encourage and maintain healthy nutrition. 
The causes which excite the dormant cachexia have been stated to be ex- 
posure to cold and damp, insufficient and unsuitable food, impure air, and 
want of exercise. It is therefore evident that a careful regulation of the 
diet, combined with warm clothing and daily exercise in the open air, must 
be the first measures to be adopted. 

With regard to food, the child should be fed liberally ; meat, fresh 
eggs, and milk should enter largely into his diet, and his stomach should 
not be overloaded with puddings and starchy matters to the exclusion of 
more strictly nourishing articles of food. Fresh vegetables are a valuable 
addition to his dietary, but potatos must be given with caution, although 
they are not to be entirely excluded. If the appetite be poor, a small 
amount of stimulant is often of service, and the child should be allowed a 
good wineglassful of sound claret diluted with an equal quantity of 
water to his dinner. It is needless to say that cakes and sweetmeats be- 
tween meals must be strictly forbidden. In the case of infants born of 
scrofulous parents, a healthy wet-nurse should be provided if the mother 
be unable to suckle her child. If this be impossible, the utmost vigilance 
must be exercised in the feeding and general management of the baby. 
Directions are given elsewhere for the healthy rearing of infants, and the 
reader is referred to the chapter on " Infantile Atrophy " for fuller informa- 
tion upon this important subject. 

Climate is a matter of great moment for children who are, or are likely 
to be, the subjects of scrofula. A bracing air is indispensable to the suc- 
cessful treatment of these cases. Eesidence in low-lying clay soils does 
much to encourage the predisposition, while sandy or gravelly places, with 
a dry air, are of the greatest benefit in increasing the vigour of the consti- 
tution. On account of the tendency to catarrhs in this diathesis, a dry air 
is of especial importance ; and a place which is sufficiently warm during 
the winter months to allow of the patient passing a large part of his time 
out of doors is of the utmost service. Large towns, with their smoke and 
vitiated air, are bad residences for scrofulous children. When compelled 
to live in cities, care should be taken that the child is warmly clothed and 
sent out as much as possible for exercise in the large open spaces with 
which most towns are now provided. For children of both sexes healthy 
out-of-door games should be encouraged ; and they should be early trained 
in suitable gymnastic exercises, such as develop the muscles and expand 
the chest. 

The skin should be kept perfectly clean by a daily bath, but cold 
douches are often too depressing for such subjects, unless employed ac- 
cording to the plan recommended for delicate children (see Introduction;. 
The bowels must be attended to, and habits should be inculcated of regu- 
larity in the use of the close-stool. WTien aperients are required drastic 
purgatives should be avoided. It is better to employ mildly acting drugs, 
such as the compound liquorice powder, or to combine an aperient with a 
tonic, as in giving the infusion of senna with the infusion of gentian or 
orange-peel. 

In treating children in whom the cachexia has become developed, the 
above matters must be carefully attended to. Great stress should be laid 
upon the value of a suitable climate in aiding the child's recovery of health. 
If possible, the patient should be sent to winter in a dry air sheltered from 
cold winds. There, dressed from head to foot in warm, woollen clothing, 
he should spend the greater part of his time out of doors. Cod-liver oil is 



188 DISEASE IN CHILDREN. 

usually prescribed indiscriminately in these cases, and while some children 
appear to be greatly benefited by the prescription, others seem almost in- 
sensible to its effects. It may be laid down as a rule that the stout scrofu- 
lous children are not the best subjects for cod-liver oil. It is the spare 
framed child with an active, nervous system who derives most benefit from 
the use of the drug. The oil should be given in doses of one teaspoonful 
two or three times a day, and its use must be continued for months to- 
gether. If the child appear to be nauseated by this constant dosing, the 
oil may be remitted for a few days at a time, but must be shortly resumed. 
On the Continent much value is attached to acorn coffee, made by roasting 
together a mixture of acorns and coffee beans and grinding them in the 
usual manner. This coffee is generally given as an adjunct to the oil. It 
is especially recommended in cases w T here there exists a chronic catarrh of 
the bowels. Cold bathing, when employed with proper precautions to in- 
duce a healthy reaction, is of vast importance in the treatment of many 
cases of scrofula. These precautions are described elsewhere (see Intro- 
duction). Cold douching is most useful in the case of stout children — those 
who derive little benefit from cod-liver oil. 

For enlarged scrofulous glands, besides the above general treatment, 
iodine combined with iron is very useful. I am in the habit of prescribing 
iodide of potassium with the tartrate of iron and glycerine, as in the fol- 
lowing mixture : 

$ . Potas. iodidi 3 i j. 

Ferri tartarati 3 j. 

Glycerini § ss. 

Aquam ad § iv. 

M. Ft. Mistura. An eighth part to be taken three times in the day. 

The iodide should be given in fair doses. The above is suitable to a 
child of five years of age, and is better than the ordinary syrup of the 
iodide of iron, the sugar of which is so frequently found to disagree. 
Some practitioners prefer the common tincture of iodide, given in doses of 
three or four drops freely diluted with water. 

Violent attacks of dyspnoea from pressure of enlarged glands upon the 
nerves of the chest are best treated at the time by strong counter-irritants. 
After the attack has subsided gentler counter -irritation may be continued. 
I have thought benefit has been derived from the careful and continued 
use of the iodine liniment to the front of the chest. 

Enlarged cervical glands are sometimes reduced by rubbing into them 
twice a day the cadmium ointment of the British Pharmacopoeia diluted 
with an equal quantity of lard. The oleate of mercury salve is also of ser- 
vice. This application should be used of the strength of five per cent. It 
must be smeared on the part, not rubbed in. It can be used twice a day 
for the first five days ; then at night only, and afterwards every other day. 
When the gland suppurates it should be opened with as little delay as 
possible, in order to avoid unnecessary scarring of the skin. It is im- 
portant, however, to anticipate the suppurative process, if possible, and 
avoid the dangers of a chronic discharging sore. Therefore if the meas- 
ures adopted to cause absorption are seen to exert little influence upon the 
size of the swelling, it is advisable to call in the aid of the surgeon. Dr. 
Clifford Allbutt strongly advocates free incision and enucleation of the 
caseous matter ; and Mr. Teale states that he has successfully treated 
many such cases by scooping out the cheesy contents of the gland, merely 
leaving the sound portions with the enclosing capsule. 



SCROFULA— TREATMENT. 189 

If softening has taken place and the abscess formed continues to dis- 
charge and often reinnames, the nightly administration of a powder con- 
taining one grain of hydrargyrum cum creta to eight grains of peroxide 
of iron is often attended with surprising benefit. This powder should 
not be given longer than for a week at a time. The sulphide of calcium 
in doses of one-fifth of a grain, given every two or three hours, is also re- 
commended. This, however, is a very uncertain remedy. Sometimes it 
succeeds, but more often it fails completely. The chloride of calcium in 
doses of five grains every four hours is sometimes successful. An im- 
portant point in the treatment of enlarged cervical glands is warmth. 
During the whole time that local applications are being used the swellings 
should be carefully protected from the cold. A good plan is to cover them 
with a thick pad of cotton-wool. 

Lugol 1 has spoken highly of iodine in all forms of scrofulous lesions. 
He used the drug as a salve to the swellings, as a lotion to the ulcers, as 
an injection to the sinuses and fistulous sores, and as a bath for the cure 
of the affections of the skin and subcutaneous tissues. Iodine tinctures 
and ointments are still favourite applications to all glandular enlargements. 
They should be used, however, with caution. I have seen serious slough- 
ing set up in a child's neck by the too energetic inunction of an iodine 
ointment into the skin over a caseous gland. 

Chronic discharges from the various mucous surfaces are best treated 
with astringent injections. Otorrhcea from catarrh of the auditory mea- 
tus, if limited to the part outside the tympanum, is readily cured by the 
following lotion : 

$ . Boracis gr. x. 

Zinci sulphatis gr. viij. 

Glycerin! 3 j. 

Aquam ad 3 j. 

Misce. 

In using this application the passage must be first thoroughly cleansed 
by injection with warm water, and then half a drachm of the lotion must 
be poured into the ear and allowed to remain. This can be done two or 
three times a day. It is important to cure a discharge from the ear as 
quickly as possible. The old notion that otorrhcea in children should not 
be checked too quickly is one which if acted upon may have serious con- 
sequences. 

1 The strength recommended by Lugol for his salve was : 

]J . Iodinii gr. vj. -x. 

Potas. iodidi 3ij.-iv. 

Adipis 3 j. 

Misce. 
For his lotion or injection : 

5 . Iodinii gr. j.-ij. 

Potas. iodidi gr. ij.-iv. 

Aq. destillatse ; § viij. 

Misce. 
For his bath, for the use of a child : 

F>. Iodinii 3 ij. 

Potas. iodidi 3 i v. 

Aq. destillatse q. s. 

Dissolve completely and add to three gallons of water of the temperature of 9S~ F. 
in a wooden vessel. This same solution he recommends as a fomentation to scrofu- 
lous lesions and sores. 



CHAPTEK II. 

ACUTE TUBERCULOSIS. 

Acute tuberculosis is an acute febrile general disease which arises, in 
most cases, as a consequence of special hereditary predisposition. The dis- 
ease expresses itself anatomically by the formation of the miliary nodule 
known as the gray granulation in the various organs of the body. This 
nodule is in great part an out-growth from the lymphatic system, and may 
be found wherever lymphatic or adenoid tissue normally exists. Acute 
tuberculosis is not to be confounded with pulmonary phthisis. Indeed, 
the two affections are essentially distinct, for ulceration of the lung, al- 
though occasionally present, is by no means a necessary part of the tuber- 
cular process. 

In the young subject acute tuberculosis frequently assumes a form 
which is rare in the adult. In childhood the disease not uncommonly 
presents itself as a primary febrile affection, giving rise to but few symp- 
toms, and those the manifestation merely of the general distress without 
any sign pointing to local mischief. It is often not until a few days be- 
fore the close of the illness that any symptoms are discovered to draw at- 
tention to any particular organ. This is the primary form of the disease, 
which has much the character of an acute specific fever. 

In other cases, almost at the same time with the beginning' of the gen- 
eral symptoms, others, more or less severe, are noticed, showing that some 
particular organ is especially fastened upon by the tubercular process. 
This form is not uncommon in cases of tubercular meningitis. 

A third form resembles that which is often met with in the adult where 
the disease arises as a secondary affection in the course of some other ill- 
ness, and in such a case brings the life of the child quickly to an end. 
This form is seen when tuberculosis supervenes upon empyema, pneumo- 
nic phthisis, etc. 

Acute tuberculosis attacks children of all ages, and may be seen in very 
young infants. When it occurs at this early age the anatomical feature of 
the disease is always very widely distributed. On the other hand, the 
older the child the more likely is it that the formation of the gray granu- 
lation will be limited to special cavities of the body. 

The word " tubercle " has been and is still employed in so vague a 
sense by various authors that it has almost ceased to convey any definite 
meaning. It may be well, therefore, to state that in the following pages 
the word is in every case used to signify the miliary nodule called " gray 
granulation " in the adult, but which in the child very quickly becomes 
yellow and opaque. 

Causation. — Hereditary predisposition plays a very important part in 
the etiology of tuberculosis. In a large proportion of cases a distinct 
family tendency to the formation of tubercle can be discovered. The ten- 
dency is not, however, always exhibited in the parents. These are often, to 



ACUTE TUBERCULOSIS — CAUSATION. 191 

all appearances, of sound constitution. It may be necessary to push our 
inquiries farther back and ask as to the health of the grandparents and of 
collateral branches of the family. In a child with this unfortunate predis- 
position, any cause which impairs the nutrition of the body may excite the 
manifestations of the tubercular tendency. Therefore lowering complaints 
and insanitary conditions generally are justly regarded as important agents 
in the production of tuberculosis. 

There are certain acute specific maladies with which the tubercular for- 
mation is very apt to be associated. Whooping-cough and measles may 
be said to number tuberculosis amongst their sequelae, so common is it to 
find children convalescent from these complaints, who are placed under 
unfavourable conditions for complete recovery, fall victims to the disease. 
Typhoid fever is sometimes followed by it. Children who suffer from mal- 
formation of the heart with narrowing of the pulmonary artery are also 
very liable to become tubercular. They do not, however, often suffer from 
acute tuberculosis. In them the disease is more apt to assume primarily 
the form of chronic tubercular phthisis, even if the distribution of tuber- 
cle become afterwards generalised. When the predisposition is strong, 
any cause which gives a shock to the system, such as a fall, a blow, or 
other similar accident, may be sufficient to excite the outbreak of the dis- 
ease. 

In addition to the cases where tuberculosis is excited in the bodies of 
persons predisposed to the affection by febrile disturbances or unwhole- 
some conditions of life, there are other instances where the disease appears 
to be set up by a local infective process. It has been well established 
by numerous experimenters that the inoculation of tuberculous matter 
into the bodies of healthy animals will produce general tuberculosis ; 
and it is held by Koch and his followers that the infecting agent in 
such cases is the minute organism known as the "tubercle bacillus." Un- 
til lately it was believed that the inoculation into a healthy animal of 
non-tuberculous or putrid matters would give rise- to the formation in the 
system of a body indistinguishable by the microscope from the gray granu- 
lation. But recent investigations have made it evident that some fallacy 
must have been present in the experiments which appeared to establish 
this result ; for a repetition of the experiments by competent observers 
have shown that no ill consequences of any kind may follow the intro- 
duction of such matters under the skin. Still, arguments drawn from 
experiments upon animals, especially upon the rodentia, which are usually 
selected for these investigations, are not perhaps strictly applicable to the 
human subject. In man the presence of softening cheesy matter in any 
part of the body may set up an infective process which is indicated by 
fever, wasting, and symptoms of general distress, and eventually by signs 
indicating implication of special organs, After death a general distribu- 
tion of small nodules which have all the characters of the gray granulation 
is found in various organs. In children a chronic empyema often induces 
such a condition, and the child usually dies with the symptoms of tuber- 
cular meningitis. Acute tuberculosis may be also set up by other forms 
of cheesy degeneration. Softening caseous glands and cheesy pneumonia 
are common exciting causes of the disease ; indeed, the scrofulous habit of 
body appears in itself to be a favouring influence, and the tissues of such 
subjects furnish a congenial soil in which the growth of the tubercular 
bodies can be readily excited. The share taken by the tubercle bacillus in 
the production of tuberculosis — whether it is the sole medium by which 
the infection is conveyed, as is maintained by some, or is merely a casual 



192 DISEASE IN CHILDREN. 

addition to the septic agent, as is believed by others— is still at the pres- 
ent moment a matter of warm debate. 

Morbid Anatomy. — The distribution of the gray granulation is very 
frequently general in the child. In the infant it is almost always so : in 
older children it may be limited to one or more cavities of the body. 
MM. Eilliet and Barthez have commented upon the curious fact that while 
in the adult, according to Louis' canon, if tubercle exist anywhere in the 
body it will be found also in the lungs, in the child the lungs sometimes 
escape altogether although every other part of the body is attacked. 
When found in one cavity of the body alone, the part affected is usually 
the skull or the abdomen. 

The gray granulation is a firm, gray, translucent, projecting nodule 
which varies in size from a fine pin's head, or even a smaller object, to a 
millet seed. In children the colour very quickly changes to yellow and 
the translucence disappears, so that whatever organ is examined gxay and 
yellow nodules (the latter usually predominating) are found mixed to- 
gether. The growth occurs, according to Eindfleisch, as the result of a 
specific irritation of the endothelia of the lymphatics, the serous mem- 
branes, and the blood-vessels, especially the former ; and the nodules are 
found to follow the ramifications of the finer arteries because the lympha- 
tics run chiefly in the adventitia of the blood-vessels. On careful exami- 
nation the miliary bodies can be seen growing upon the fine vessels, in- 
volving the whole calibre of the channel in the smallest arteries, and in 
those a degree larger forming protuberances on one side. Eindfleisch de- 
scribes the granule as a product of inflammation, and states that it consists 
in an increasing accumulation of leucocytes in the connective tissue of the 
part irritated. Of these white cells a portion take on an epithelioid char- 
acter. These grow to three or five times the size of a white blood corpus- 
cle and are called tubercle cells. Others develop into the irregular 
branching bodies called " giant-cells." The giant-cells are not, however, 
as was at one time supposed, peculiar to tubercle. ScliLppel believes that 
they arise within a blood-vessel from the accumulation and adhesion of 
tenacious masses of molecular matter. When they have reached a size 
which causes distention of the vessel, nuclei begin to appear. According 
to this observer, the epithelioid cells are derived from processes of the 
giant-cells. They lie around the latter and constitute the greater part of 
the nodule. According to most observers, a section of the tubercles, after 
they have been some time in existence, shows a delicate reticulum, the 
meshes of which contain the cells. This, however, is denied by others. 

In proportion as the tubercular body enlarges by accumulation of cells 
the central part is found to degenerate, and when examined at this stage 
[i.e., after degeneration has begun) it will be seen to consist in great meas- 
tu*e of small, shrivelled, and granular cells. 

The presence of the gray granulation in any tissue is usually quickly 
followed by inflammation in the neighbourhood of the growths. In the 
case of a serous membrane, such as the meninges of the brain or the peri- 
toneum, lymph is quickly thrown out, and, if time be allowed, becomes 
caseous. In the lungs an early consequence is bronchitis and catarrhal 
pneumonia. In these organs the granules very quickly become yellow and 
caseous, and every stage of degeneration of the nodules is usually to be 
discovered. Dr. Wilson Fox has described in the lungs of children dead 
from tuberculosis : gray translucent granulations ; opaque white gran- 
ules — soft, but of varying firmness and resistance ; the same, but caseous 
in the centre ; yellow granulations, very soft and easily crushed ; cheesy 



ACUTE TUBERCULOSIS — MORBID ANATOMY, 193 

granules — dry, opaque, and friable, with or without a surrounding zone of 
gray transparent matter ; groups of the latter forming little masses the 
size of a pea, bean, or even walnut ; indurated pigmented granules, single 
or in groups ; and, lastly, tracts of variable size and irregular outline, 
granular on the surface, passing insensibly into the so-called " gray infil- 
tration." Sometimes, also, he noticed little cavities from softening of the 
tubercular masses. There were, in addition, signs of secondary catarrhal 
pneumonia and its consequences. 

Ulceration of lung and the formation of cavities is not a common con- 
sequence in early life of acute pulmonary tuberculosis. In infants in whom 
the disease runs a rapid course this lesion is very exceptional. It is, how- 
ever, sometimes met with. Thus, in an infant, aged eight months, with 
four teeth, who died in the East London Children's Hospital of acute gen- 
eral tuberculosis with secondary broncho-pneumonia and meningitis, tu- 
bercles, gray and yellow, were found after death occupying all the cavities 
in the body. They were discovered at the base of the brain, on the peri- 
toneum, in the substance of the liver, spleen, and kidneys. The lungs were 
completely stuffed with them, and in the lower lobe of the left lung a small 
cavity had formed of the size of a hazel-nut. Such a condition is, however, 
not common. Even in older children, although the duration of the illness 
is longer, breaking up of the lungs, as a consequence of acute tuberculosis, 
is comparatively rarely seen. 

In the intestines the gray and yellow granulations are seated especially 
in the smaller bowel, and involve principally the iliuin and the part of the 
caecum in the neighbourhood of the valve. The nodules he in the sub- 
mucous tissue, and in the acute form of the disease do not, as a rule, give 
rise to ulceration. In the liver the tubercles are developed on the smallest 
ramifications of the hepatic artery. They may be seen under the serous 
coat, and are also found in the interlobular spaces and in the interior of 
the lobules. They are usually few in number. In addition to being the 
seat of tubercle, the organ is often found to present other pathological 
characters not especially distinctive of the tubercular disease. Thus, it 
may be enlarged from a simple hypertrophy or from fatty infiltration, and 
is sometimes the seat of a cirrhotic change. In the latter case it may give 
rise to ascites. 

The spleen is one of the organs most commonly attacked by tubercle. 
Gray and yellow granulations and large cheesy masses may be found, so 
that the size of the organ is considerably increased. In the kidneys mili- 
ary nodules may be thinly scattered through the parenchyma. The little 
masses are developed, as elsewhere, in the sheath of the smallest arteries. 
Sometimes more extensive disease is met with, and large masses of cheesy 
matter are formed which soften and give rise to tuberculous ulcers. These 
may penetrate deeply into the renal tissue. According to Rindneisch the 
disease begins in the papillary portion of the gland, spreading from the 
mucous lining of the calices. In extreme cases the kidney is converted 
into a thick-walled sac, with hemispherical protrusions, each of which cor- 
responds to a Malpighian pyramid. The bladder is sometimes involved, al- 
though comparatively rarely in early life. Miliary nodules appear in the 
submucous tissue and soften, giving rise to circular ulcers the edges of 
which are found on examination to be infiltrated with closely packed gray 
and yellow granulations. 

In addition to the lesions which have been mentioned, the bronchial 
and mesenteric glands are always enlarged and cheesy. Sometimes they 
are softened. 

13 



194 DISEASE IN CHILDEEN. 

How far the cheesy matter, which is often found in large quantities in 
the more prolonged cases of pulmonary tuberculosis, is to be regarded as 
tubercular is a question upon which opposite opinions are held. Virchow 
and his followers look upon all such caseous matter as the consequence of 
catarrhal pneumonia ; and there is no doubt that the miliary nodule is 
primarily an extra-alveolar growth, while the caseous masses, such as are 
found in cheesy pneumonia, take their origin from a proliferation of the 
epithelial elements in the air-cells. Before the giant-cell was known to 
be a constituent of other than strictly tubercular structures, the presence 
of this cell was held to be confirmatory of the tubercular nature of the 
pathological product. Now the presence of the bacillus is considered by 
many to point to the same conclusion. But is the question one which can 
be determined solely upon anatomical grounds ? The clinical history of 
the disease is surely \ not unimportant element in the solution. It is gen- 
erally admitted that the closest examination discovers in the gray granula- 
tion no peculiarity of structure which can be relied upon to separate the 
nodule from other bodies having a like appearance, and under the micro- 
scope all cheesy matter has very similar characters. The case is one in 
which the clinical features of the malady should have an exceptional value 
in determining the nature of the pathological product ; for if two diseases 
are found to differ widely in the mode of origin of the attack, in the nature 
of the symptoms, and in the course of the illness, we may hesitate to ad- 
mit identity of nature, however close may be the resemblance in the ana- 
tomical conditions. 

Symptoms. —Primary tuberculosis in the child commonly assumes the 
form of an acute general disease. It excites moderate pyrexia and marked 
interference with nutrition, and from the indefinite character of the earlier 
symptoms and the absence of any manifestation of local distress, often 
presents great difficulty in the diagnosis. Sooner or later signs are dis- 
covered pointing to disease of special organs: cerebral symptoms arise, 
or there are indications of pulmonary mischief. Tubercular meningitis 
and cerebral tubercle are described at length in special chapters. The 
present description is confined to cases where the disease is general, and 
where the local symptoms are limited to the lungs and other organs not 
elsewhere referred to. 

Children who fall victims to acute tuberculosis, although often of deli- 
cate appearance, are not necessarily thin and feeble-looking. In many 
cases the nutrition of the patient is very good, and the child is considered 
to be in every way a healthy subject until the disease appears. It is not 
at all uncommon, especially in cases where the chief violence of the malady 
is expended upon the cerebral meninges, to find that up to the time of his 
illness the child had never suffered from a day's indisposition. In other 
cases the patient has been noticed to be sensitive to chills and prone to at- 
tacks of indigestion. These latter children are often of frail appearance 
and have the "tubercular aspect." Their skin is thin and transparent, 
their hair fine and silky, their features regular and delicate, their bones 
small, and their shoulders narrow and sloping. 

Acute tuberculosis may begin gradually or suddenly. In exceptional 
cases the disease has an abrupt beginning. There is high fever, headache, 
epistaxis, relaxed or confined bowels, and the child is very restless and 
stupid. But this mode of beginning is very rare. In the large majority 
of instances the onset is so insidious that there is a difficulty in fixing upon 
a date for the beginning of the attack. The earlier symptoms, as has been 
said, are so slight and vague, and the child passes so gradually from health 



ACUTE TUBEECULOSIS — SYMPTOMS. 195 

to sickness, that the mother is usually quite unable to determine when 
she first noticed any signs of indisposition. She will say that for some 
weeks the child had seemed to be less brisk and lively than was his wont ; 
that he would often lie about instead of playing ; and that his appetite 
had seemed to fail ; but that no special importance was attached to these 
symptoms until something more definite was noticed which excited alarm. 
The first influence of the disease is upon general nutrition. The child be- 
gins to look pale, with a curious transparent pallor. His conjunctivae have 
a bluish tint, and the lower eyelid is discoloured. He loses his sprightli- 
ness and gets dull and moping; his appetite is poor, and he falls off in his 
flesh. A certain amount of fever usually accompanies this condition. In 
the evening the cheeks may be brightly flushed, and the hands and feet 
feel hot to the touch. At this time a thermometer in the axilla marks be- 
tween 100° and 101°. The patient is thirsty, and often asks for water in 
the night. In the morning the temperature is normal ; but the child when 
he leaves his bed generally looks pale and distressed. The anxious ex- 
pression of the face in these cases is indeed commonly a noteworthy phe- 
nomenon ; and if combined with mildness of the general symptoms, and 
complete absence of all signs of local discomfort, is an indication of illness 
of very serious moment. In some cases there are repeated attacks of chilli- 
ness followed by heat ; and these may have a periodicity which suggests 
suspicions that the child is suffering from ague. The chilliness, however, 
seldom amounts to shivering, and sweating is scanty or absent. Loss of 
flesh is never very long in showing itself. The wasting is often very 
gradual, unless some relaxation of the bowels is present, and in the major- 
ity of cases is intermittent. In hospital patients, under the unaccustomed 
influence of good food and nursing, it is not uncommon for a child to re- 
gain some of the flesh he had lost, although all the time the fever con- 
tinues and the general disease is pursuing its regular track. Even in 
children who are living in better circumstances the progress of the illness 
is often very unequal — the child seeming to be alternately better and 
worse, and the temperature fluctuating curiously from day to day. Some- 
times, indeed, the pyrexia is found entirely to subside, and for a few days 
the improvement may be such that recovery is confidently anticipated. 
The intermission is usually, however, of short duration, and the patient 
relapses into his former state. At this time a common symptom is oedema 
of the legs and sometimes of the face, and the urine may contain a trace 
of albumen. In young babies the only symptoms of the disease for a con- 
siderable time may be slight fever, pallor, some loss of flesh, an inelastic 
state of the skin, and a little oedema of the extremities. 

For the first few weeks the above general symptoms are all that can be 
discovered ; and the most careful examination detects no cause to which 
the evidently serious condition of the child can be referred. He is thin, 
pale, weakly, and listless ; but his tongue is clean, and although feverish 
and restless at night, he sleeps fairly well, is not light-headed, and in the 
daytime makes no complaint. His abdomen is normal, rather flattened 
than distended ; there is no enlargement of the liver or spleen — at least 
during the first few weeks of the illness ; and pressure of the belly elicits 
no sign of tenderness. In some cases a few rosy spots, rather more red 
than the typhoid spot, and of a larger size, are noticed on the abdomen 
and chest. The skin generally is dry and harsh. 

After a time local symptoms arise. These often point to cerebral irri- 
tation. An attack of convulsions occurs, followed by squinting ; the pupils 
are dilated ; there is drowsiness and rigidity of joints ; and the child dies 



196 DISEASE IN CHILDREN. 

with all the symptoms of tubercular meningitis. It other instances the 
cranial cavity escapes, and symptoms are noticed showing implication of 
the lungs. 

The first local sign of acute pulmonary tuberculosis is cough. This is 
short and hacking, and in the earlier period not very frequent. It may 
be accompanied by some hurry of breathing ; but the respirations are not 
always increased in rapidity, and even at an advanced stage of the disease, 
if there be only a moderate amount of catarrh, may be little, if at all 
more rapid than in health. The cough at this time is not accompanied by 
any abnormality of physical signs. Kepeated examination of the chest 
discovers no dulness on percussion ; and an occasional click of rhonchus 
or a sibilant wheeze may be the only phenomenon present. In some cases 
the child dies without any fresh symptoms ; but usually a secondary bronchi- 
tis develops after a time. The breathing then becomes rapid, the face is 
haggard and livid, and the nares dilate in inspiration. The pulse is small 
and rapid, and there may be some slight perversion of the pulse-respira- 
tion ratio ; but this never occurs to the degree noticed in cases of broncho- 
pneumonia. The temperature rises, and may reach 103° in the evening, 
sinking to 100° in the morning. With the stethoscope we now find the 
breath-sounds covered by a crisp, bubbling rhonchus, which occupies the 
whole extent of both inspiration and expiration. If the breathing can be 
heard through the rhonchus, it is not bronchial although the expiration 
is perhaps prolonged. There is no dulness if collapse be absent ; but 
sometimes local collapse of small extent occurs at the apex ; and we may 
find a little local dulness at the supra-spinous fossa, or above the clavicle, 
with faint bronchial breathing. There is nowhere any increased resonance 
of voice or cough. 

The above signs may persist without alteration to the close. Often, 
however, the inflammation passes into catarrhal pneumonia. Patches of 
dulness are then discovered at the apex or elsewhere. At these spots the 
breathing is blowing or tubular ; the rhonchus becomes crisper, finer, and 
more crepitating in character ; and the vocal resonance may be intensely 
bronchophonic. The patches of consolidation, as in cases of the non- 
tubercular inflammation, may coalesce until large areas of tissue are solid- 
ified. 

The occurrence of broncho-pneumonia is also indicated by increased 
severity of the previous symptoms. The lividity deepens ; the breathing 
becomes laboured ; the soft parts of the chest and epigastrium sink in at 
each inspiration ; the nails become purple, and the superficial veins of the 
extremities are fuller than in health. The temperature also rises to a 
higher level, and may reach 104° or 105° in the evening. When these 
symptoms are noticed the illness is very near its close ; indeed, the child 
seldom survives longer than a day or two. Death may be preceded by a 
fit of convulsions, due either to meningitis or asphyxia. 

A little girl, aged ten, with a consumptive family history, was a pa- 
tient in the East London Children's Hospital. The child was said to have 
suffered when quite young from measles, whooping-cough, and scarlatina, 
but had recovered perfectly from each, although the latter had been fol- 
lowed by dropsy. She had also had an attack of ague when between two and 
three years of age. Still, the child had been in fair health until six weeks 
before admission. Her illness had begun suddenly, but the symptoms at 
first were not marked. She had seemed generally poorly, but did not lose 
flesh to any considerable extent ; nor was she troubled with cough for the 
first three weeks. When the cough began it was short and dry, but not 



ACUTE TUBERCULOSIS — SYMPTOMS. 197 

distressing. Three days before admission it had become loose, and the 
child had expectorated some yellow phlegm. After the cough began she 
was noticed to waste and to be feverish, sweating much at night. For a 
week her feet had been a little swollen. 

On admission the child's expression was anxious. There was some 
lividity of the face, and in the evening her cheeks flushed brightly. Her 
tongue was clean and her bowels regular. Temperature at 7 f. m., 100. 1 c . 
On examination of the chest the percussion-note was slightly high-pitched 
above the clavicles, but elsewhere was normal. Everywhere about the 
chest the breath-sounds were concealed by a metallic bubbling rhonchus. 
This was coarser behind than in front, and occupied the whole extent of 
both inspiration and expiration. The vocal resonance was normal. A 
rhonchal fremitus could be felt everywhere about the chest. 

After admission the physical signs persisted with little alteration. The 
dulness disappeared from the apices and none could be detected elsewhere. 
The pulse was very rapid, 150-168; respirations, 60-68 ; temperature each 
evening, 101°— 102.4°. After a few days the lividity deepened ; tl^e child 
became very restless, and she died on the ninth day — the fifty -first day of 
her illness. 

On examination of the body gray or yellow miliary nodules were found 
in the liver, spleen, and kidneys. Gray granulations were also seen under 
the serous coat of the small intestine, and were numerous on the pia ma- 
ter. The lungs were stuffed with tubercle throughout, and the nodules 
formed projections on the surface underneath the pleura. The nodules 
varied in size, the largest not exceeding a hemp-seed in diameter. The 
lung tissue between them was of a deep red colour and tore readily. It, 
however, floated in water. The mediastinal glands were enlarged and 
cheesy, and one or two were softened. 

Besides the parts which have been mentioned, tuberculosis sometimes 
involves the urinary apparatus. The kidneys indeed are often affected, and 
the consequent congestion is no doubt a cause of the slight albuminuria 
which is a common symptom of the affection. But besides the kidneys, 
tuberculosis may occur in the bladder. This lesion is more common in 
the adult than in younger subjects, but is met with from time to time in 
the older children. As it gives rise to many of the symptoms of vesical 
calculus this form of tuberculosis must not be passed over without a word 
of mention. 

The presence of miliary tubercles in the bladder sets up a cystitis, and 
gives rise to symptoms which are attributed almost invariably to stone. 
There is great irritability of the bladder and increased frequency of mictu- 
rition ; and according to Guebeard, these symptoms are more marked at 
night than during the day. At the end of the flow of urine some pus may 
be passed, or a drop of blood may appear at the extremity of the urethral 
canaL There may be pain, which is referred to the region of the bladder, 
and the passage of urine is often accompanied by uneasiness. Sometimes 
micturition is only effected by straining, during which the rectum may pro- 
lapse. The urine may be normal, but often is cloudy and thick. It may 
contain a trace of albumen. The temperature and general symptoms of 
tuberculosis are present in these cases. Exploration of the bladder with a 
sound discovers no calculus ; but digital examination by Volkmann's 
method (i.e., passing a finger into the rectum and palpating with the other 
hand above the pubes) sometimes detects a tubercular nodule at the fun- 
dus of the bladder. 

In the stomach, intestine, liver, and spleen the development of tubercle 



198 DISEASE IN CHILDEEN. 

rarely gives rise to sufficient local symptoms .o furnish grounds for diag- 
nosis. In the stomach the lesion may excite digestive trouble ; but even 
this is an uncommon consequence of the disease, and when present is sig- 
nificant merely of catarrh of the mucous membrane. Bignon, indeed, has 
reported a case in which a child died after vomiting a large quantity of 
blood, and on examination of the body an ulcer was found at the larger 
curvature surrounded by tuberculous nodules. This case is, however, a 
very exceptional one. In the intestine the lesion seems to excite no symp- 
toms whatever. The spleen, if thronged with masses of tubercle, may be 
enlarged ; but the liver is rarely increased in size from this cause. It is, 
however, sometimes the seat of fatty infiltration. 

The duration of acute tuberculosis in the child is seldom prolonged. 
In infants it may last six weeks or two months ; in older children some- 
what longer. The length of the illness principally depends upon the du- 
ration of the early stage, for when local symptoms occur showing im- 
plication of special organs, the disease usually runs rapidly to its 
close. 

Diagnosis.. — The disease with which acute tuberculosis is most apt to 
be confounded is typhoid fever. This is especially the case when the tu- 
bercular affection begins abruptly with high fever, headache, and bleeding 
from the nose. A diagnosis is then impossible at the first ; indeed it is 
often only by the after-course of the illness, and the prolongation of the 
pyrexia beyond the time when in typhoid fever a fall of temperature may 
be looked for, that suspicions are excited of the real nature of the disease. 
The diagnosis between an ordinary case of acute tuberculosis and typhoid 
fever is given elsewhere (see page 83). 

Sometimes cases of acute gastric catarrh may present considerable re- 
semblance to acute tuberculosis in its early stage. Not long ago I was 
consulted about a boy, seven or eight years of age, who had at one time 
suffered to my own knowledge from slight consolidation of the right apex, 
the consequence of an attack of catarrhal pneumonia. The boy was of 
scrofulous type, thin and pale. He was said to have been losing flesh for 
some time and to have had a poor appetite. For more than a week his 
appetite had been exceptionally bad ; his temperature had been raised, and 
he had had a hacking cough. I saw the boy at 5 p.m., with Dr. J. IN. Miller, 
whose patient he was. The boy's temperature was then 100.2°. He was 
pale with no flush on his cheeks ; and his face was bright and lively with- 
out any sign of distress. His chest was everywhere perfectly normal, 
except for a little dry rhonchus about the back. His belly was not dis- 
tended. There was no enlargement of the liver or spleen, and no swollen 
mesenteric glands could be felt. He had no sore throat. The tongue was 
furred, and the breath had a faint unpleasant smell. There was no albu- 
men in the water, nor any trace of oedema of the legs. The spirits of the 
child were said to be remarkably good ; and I was told that that morning 
he had been seen attempting the acrobatic feat of standing on his head. 
This latter fact, joined with the bright expression of the boy's face, the 
signs of gastric derangement, and the absence of all evidence of pulmonary 
mischief, appeared to me to afford sufficient ground for excluding tuber- 
culosis. I accordingly expressed an opinion that the boy was suffering 
merely from a subacute attack of gastric catarrh. Shortly afterwards I 
heard that the febrile symptoms quickly disappeared. 

According to my experience, children suffering from the development 
of tubercle are invariably dull and spiritless, and usually show signs of 
distress in the face. If a boy jumps about and plays boisterously, as if he 



ACUTE TUBERCULOSIS— DIAGNOSIS. 199 

were well, acute tuberculosis may be excluded with a high degree of prob- 
ability. 

The detection of acute tuberculosis depends in a great measure upon 
the absence of symptoms capable of explaining differently the serious con- 
dition of the patient. If a child is brought with a history of fever and 
wasting of some weeks' duration, if he looks ill, with a distressed haggard 
face, and if a careful examination of the whole body discovers no disease 
of organs, the state of the child is evidently not to be attributed to any 
local cause. In such a case the diagnosis will he between typhoid fever 
and tuberculosis, and if from the duration of the illness, or for reasons 
given elsewhere (see page 83), typhoid fever can be excluded, we shall be 
reduced to tuberculosis as the only other probable explanation of the 
child's state. In a badly fed infant who has been irregularly feverish from 
teething, and whose nutrition has been some time defective, the history of 
wasting and pyrexia may raise suspicions of tuberculosis. But in such a 
case the child will not look haggard and pinched like one suffering from 
that disease ; the irregular and often greatly elevated temperature of den- 
tition is unlike the moderate pyrexia of the tubercular affection, and will 
be sufficiently explained by inspection of the gums. Moreover, the history 
of the illness, which will almost certainly include several attacks of diar- 
rhoea or sickness, and the account of the child's diet will furnish an amply 
sufficient explanation of his continued indisposition. In an infant acute 
tuberculosis is almost always accompanied by oedema of the legs. At this 
period of life the combination of wasting, moderate pyrexia, and oedema of 
the lower limbs is a very suspicious one. 

Even when the case is first seen in its later stage, after signs of local 
disease have become evident, the diagnosis is not always easy. The physi- 
cal signs of tuberculous bronchitis have no special character distinctive of 
their specific origin, and they must be read in the light afforded by the 
history and course of the illness in order that they may be lightly inter- 
preted. In tuberculous bronchitis the temperature is higher than is found 
in an uncomplicated case of the catarrhal disease. In simple capillary 
bronchitis the pulmonary affection is seldom accompanied by marked 
pyrexia, and the mercury rarely rises higher than 101° in the evening. In 
tuberculous bronchitis, on the other hand, a temperature of 104° is not 
uncommon. The chief point, however, is the occurrence of the bronchial 
disorder in a child worn and weakened by illness of undefined character 
and accompanied by fever and wasting. If this illness have succeeded 
after a variable interval to an attack of whooping-cough or measles, the fact 
alone should raise a suspicion of the tuberculous nature of the pulmonary 
complaint. So, also, if broncho-pneumonia supervene, with spots of local 
consolidation, the history of previous ill health is essential to a right un- 
derstanding of the nature of the child's complaint. In either case the 
onset of symptoms pointing to intracranial mischief is of the utmost 
value in confirming our suspicions ; and if convulsions occur, followed by 
squinting, ptosis, unequal pupils, and rigidity of the joints, the tubercu- 
lous nature of the disease may be considered to be established (see also 
page 440). 

In tuberculosis of the bladder the child's distress is usually attributed 
to the presence of a vesical calculus. There is, however, oue diagnostic 
point of considerable importance. The irritation excited in children by a 
stone in the bladder is rarely a cause of noticeable pyrexia, while, when the 
symptoms are due to vesical tuberculosis, the evening temperature may 
reach 102° or higher. Moreover, digital examination after the manner re- 



200 DISEASE IN" CHILDREN". 

commended by Volkmann, already referred to, will sometimes detect a 
tuberculous nodule in the fundus of the bladder. 

Prognosis.— The prospects of a child in whom acute tuberculosis has 
revealed itself unmistakably are very desperate. In the earlier stage of the 
disease, while any uncertainty exists as to the nature of the illness, we can 
still hope ; but when a secondary bronchitis or catarrhal pneumonia arises, 
or signs of intracranial mischief are noticed, death may be considered cer- 
tain. Attacks of gastric catarrh in children with tuberculous and scrofu- 
lous tendencies are almost invariably accompanied by fever. If the attack 
is protracted or rapidly recurs, an intermittent pyrexia may continue for 
some weeks, and on recovery the child may be thought to have passed 
through an attack of tuberculosis. Probably most instances of alleged 
recovery from acute tuberculosis are cases of this kind. 

Treatment. — When a case of acute tuberculosis has occurred amongst 
the younger members of a family very special measures should be taken 
to preserve the health of those who remain. They should sleep in well 
ventilated rooms, be warmly clothed, and be taken out of doors regularly 
for exercise. Such children should, if possible, live much in the country 
on a sandy or gravelly soil, and should avoid the vitiated air of towns. 
Their diet should be plain, and excess of sweets and fermentable matter 
should be forbidden. Children with tubercular tendencies should not be 
taught too early. It is wise to postpone regular education until they 
reach their sixth or seventh year ; and every care should be taken that 
their sensitive brains are not overtasked. The mother, if herself of frail 
constitution, should be forbidden to suckle her infant, and a healthy 
wet nurse should be provided. Any signs of indigestion in such sub- 
jects should be promptly treated, and the utmost vigilance should be 
exercised to maintain the nutritive processes of the body at a healthy 
standard. 

All catarrhs, however mild they may be, should at once receive atten- 
tion, and the parents should be warned of the danger of treating the child 
as if he were well before all signs of his temporary ailment have disap- 
peared. Acute diseases, especially the exanthemata, have peculiar dangers 
for these children ; and during the period of convalescence the patients 
should be put into the most favourable conditions for insuring complete 
recovery. A good sea air should be always advised in these cases as soon 
as the child is well enough to be moved from his home. 

When the disease declares itself no drugs appear to have any value in 
arresting its course, and very little in retarding the fatal issue. Some- 
thing may be done by treating symptoms and putting a stop to enfeebling 
complications. Thus the looseness of the bowels, which is often an early 
symptom of the disease, may be usually controlled by a powder containing 
three or four grains of rhubarb with double the quantity of aromatic chalk 
powder every night ; and twice a day a draught containing dilute sulphuric 
acid (TTj, iij.-v.), with tinct. opii (TT[ 3 - — i j - ) , and a few drops of glycerine in 
a teaspoonful of water. Sometimes the carbonate of bismuth in full doses 
(gr. x.-xx.) may be substituted with advantage for the rhubarb in the 
powder. If in spite of these remedies the looseness still continues, gallic 
acid (gr. ij.-v.) can be given with laudanum. 

It is very difficult to reduce the pyrexia in acute tuberculosis. Large 
doses of quinine have no more than a temporary effect, and often appear to 
be quite useless ; salicylic acid and its compounds have little beneficial 
influence ; and the hypophosphites have not in my hands been followed by 
satisfactory results. The hypophosphite of lime, however, although it 



ACUTE TUBERCULOSIS— TREATMENT. 201 

does not reduce the heat, is useful in alleviating the various forms of 
catarrh so common in tuberculous children, and often has a sensible 
influence in improving the appetite, and sometimes, temporarily, the 
strength. 

Inflammatory chest affections must be treated upon ordinary principles. 
As the strength of the child declines, stimulants will be required, and the 
brandy -and-egg mixture must be resorted to. The diet should be such 
as is recommended for other febrile diseases. 



CHAPTER III. 

INFANTILE SYPHILIS. 

Syphilis in the infant is generally the consequence of an inherited 
taint. It then presents a combination of the so-called secondary and 
tertiary stages of the disease. Sometimes, however, it is acquired, and 
there is then a primary lesion as in the adult. In this latter case the 
symptoms resemble more those of constitutional syphilis acquired after 
puberty. Still, the progress of the disease is not entirely uninfluenced by 
the tender age of the patient, for in after-childhood we can often discover 
many symptoms which are common to the inherited form of the malady. 

Causation. — The congenital taint may be derived from either the 
father or the mother ; and the severity of the transmitted disease is in 
direct proportion to the shortness of the time which has elapsed since the 
appearance of constitutional symptoms in the parent. 

The disease may originate with the father. In this case much discus- 
sion has arisen as to the mode in which the mother becomes affected, or 
as to whether she becomes affected at all. In cases w T here there is no evi- 
dence of direct contagion, it has been held by some observers that the 
mother may be infected by tainted spermatic fluid, although no primary 
lesion is produced. Others believe that the infection only takes place at 
the time when conception occurs ; others, again, deny that even in this 
case can infection be conveyed ; while a fourth class insists that when the 
mother becomes herself syphilitic the virus is introduced only indirectly, 
being absorbed into her system from the tainted embryo. This discussion 
has, no doubt, great scientific interest, but is of little practical value. Of 
far greater importance is it to remember that a man may beget a syphilitic 
child long after constitutional symptoms have ceased to appear in his own 
person. From the researches of Dr. Kassowitz it appears that when left 
untreated, a series of years — six, eight, ten, or even more — may elapse be- 
fore a man is relieved from the obligation of transmitting the taint to his 
offspring. When mercurial treatment is adopted, the remedy destroys for 
a time the power of the virus, and the parent is then capable of begetting 
a healthy child. But this immunity from transmitting the disease is not 
permanent. In some cases the influence of treatment becomes exhausted 
after a longer or shorter time, and the poison recovers something of its 
former virulence. 

With regard to the escape of a mother who has borne a syphilitic child, 
it seems certain that the escape must be incomplete, for she acquires a 
strange immunity from further infection. Long ago Colles laid it down 
as a canon that " a new-born child affected with inherited syphilis, even 
although it may have symptoms in the mouth, never causes ulceration of 
the breast which it sucks, if it be the mother who suckles it, although contin- 
uing capable of infecting a strange nurse." This law holds good as com- 
pletely now as when Colles wrote in 1837 ; and it is difficult to understand 



INFANTILE SYPHILIS — CAUSATION— MORBID ANATOMY. 203 

how the mother can be proof against the poison unless she be herself the 
subject of the disease. 

Still, there is no question of the apparent immunity of many women 
the mothers of syphilitic children. Dr. Kassowitz has brought forward 
instances to prove that the most careful examination, combined with watch- 
ing extending over many years, may fail to detect signs of syphilis in women 
who have borne diseased children. It certainly does appear possible that, 
as Mr. Hutchinson believes, a woman may have a form of disease too fee- 
ble to give rise to external manifestations, but strong enough to protect 
her from farther contamination. Mr. Berkeley Hill insists that in all these 
cases the escape of the mother is not real. He believes, too, that in most 
cases she has contracted syphilis in the usual manner by direct contagion, 
but that the primary sore has escaped notice through examination having 
been delayed too long after the date of infection. 

The mother alone may be diseased, the father being healthy. In this 
case if the mother have contracted the disease shortly before conception, 
and exhibit the secondary rash during her period of gestation, the child 
probably never escapes. If four or more years have elapsed since her in- 
fection at the time when she becomes pregnant, she may have lost her 
power of transmitting the disease and the child may be spared. 

If the mother be actually pregnant when the virus first enters her sys- 
tem, she may or may not communicate it to her offspring. Much depends 
upon the period of gestation at which infection took place. The more ad- 
vanced the disease in the mother before her confinement, the more likely is 
the infant to inherit the taint ; and if a secondary rash have appeared upon 
the mother's body before the end of her pregnancy, the child usually suffers 
severely from the transmitted disease. In the initial stage of the malady 
the power of the mother to impart the taint is less certain ; and it is im- 
probable that the foetus can be infected if the parent have not herself 
suffered from constitutional symptoms. Therefore, if she only contract the 
disease towards the close of her pregnancy, the infant has a fair chance of 
escape. There is no evidence to show that the disease contracted by the 
mother after the eighth month of her pregnancy can be communicated to 
the foetus in her womb. 

The influence of mercurial treatment in destroying the transmissive 
power is very decided. If a woman who has borne a dead or diseased 
child be properly treated before or during her next pregnancy, the infant 
borne after treatment will be either perfectly healthy or will suffer very 
slightly from the inherited taint. Still, as in the case of syphilis in the 
father, the counteracting power of the remedy is apt to be diminished by 
time. 

When a healthy infant acquires the disease after birth, it is usually dm'- 
ing lactation, the nipple of the mother or nurse having become infected 
by the mouth of another child who suffers from the disease. It is doubt- 
ful if the milk alone of a syphilitic woman is capable of communicating the 
complaint. Again, accidental contact with specific purulent discharges, 
whether from a primary sore or a secondary lesion, may impart the disease. 
Iu either case the sore produced in the child is a primary one. Another 
method by which the syphilitic poison may be conveyed to a healthy child 
is by vaccination. The possibility of such communication was long denied ; 
but many well-authenticated cases in which this deplorable accident has 
occurred have now been published, and the evidence in its favour is com- 
plete. 

Morbid Anatomy. — Infantile syphilis, like the other diathetic diseases 



204 DISEASE IN CHILDREN. 

of childhood, may affect the tissues very widely. The pathological charac- 
ters may be divided into three classes, according as to whether the part affect- 
ed is a mucous membrane, a solid organ, or a part of the bony frame-work. 

The mucous membrane may be the seat of catarrh, of mucous patches, 
or of ulcers. All these may be seen on the inside of the cheeks and lips, 
the fauces, and sometimes the small intestine ; also upon the larynx, the 
trachea, and even the bronchi. 

The inside of the mouth is a common seat for erosions and mucous 
patches. They do not spread down the gullet, according to Dr. John 
Mackenzie ; nor are they to be seen on the posterior wall of the pharynx. 
In rare instances syphilitic ulceration is found in the small intestine. I 
once saw a little boy — four years of age — the subject of obstinate diar- 
rhoea, in whom the evacuations had all the characters usually found in cases 
of ulceration of the bowels. His father had had syphilis, and his mother 
in her next confinement gave birth to a distinctly syphilitic child, and had 
afterwards several miscarriages. The case resisted all ordinary remedies, 
but was eventually cured by the continued application of a mercurial oint- 
ment to the abdomen. 

Mucous patches and ulcers may be seen on the glottis and epiglottis. 
The vocal cords may be destroyed by ulceration or may be the seat of 
warty growths. A case is elsewhere related (see page 417) in which ob- 
struction of the larynx by warty growths occurred in a child who had a 
past syphilitic history, but in whom no other constitutional lesion could 
be discovered. Sometimes great thickening is noticed in the mucous 
membrane of the glottis. Thus, in a case reported by Eross — a syphilitic 
child aged three and a half years — a laryngoscopic examination showed 
that the epiglottis was thickened to three or four times its natural size ; 
the ary-epiglottidean cords were thickened and pale red ; the left vocal 
cord was more than twice as thick as the right, and bulged out at its edge 
towards its fellow. The symptoms were aphonia, and frequent convulsive 
fits of coughing with suffocative attacks. The child was treated with mer- 
curial inunctions, and was well in two months and a half. According to 
Dr. T. Barlow, the larynx, even after recovery, is left very sensitive and 
susceptible to fresh catarrh. The mucous membrane of the trachea and 
bronchi may be affected in a similar way. There may be catarrh, or mu- 
cous patches, or shallow ulcers ; but these lesions are less common here 
than at the upper part of the respiratory passage. In rare cases the ul- 
ceration may be extensive. Thus, Woronichin found in a child of fourteen 
months old ulceration of the lower part of the trachea, and a similar lesion 
of the right bronchus which extended as far downwards as the next di- 
vision of the air-tube. 

In solid organs syphilitic lesions assume the form of fibroid growths, 
which may be either diffused or circumscribed. Whatever organ be af- 
fected, the nature of the lesion is the same, There is hyperplasia of the 
connective tissue of the part. This grows, thickens, and finally contracts, 
so that the proper parenchyma of the organ is obliterated and replaced by 
a solid fibroid material. When the lesion is circumscribed it is called 
" gumma." This has essentially the same structure as the diffused form, 
but tends to soften in the centre by a process of fatty degeneration. 

Diffused fibroid change is seen in the lungs, liver, spleen, and pancreas. 
Gummata have been found in the same organs ; also in the heart and sub- 
cutaneous tissue. Occasionally they are found also in the tongue and soft 
palate, but not in infants. This is a later symptom and seldom occurs be- 
fore the end of the sixth year, 



INFANTUM SYPHILIS — MORBID ANATOMY. 205 

In a lung the seat of diffused fibroid change, the part is solid and gray 
in colour, with a smooth shining section traversed byline fibrous lines. It 
is very dense and tough. Under the microscope the alveolar walls are seen 
to be infiltrated with round cells, spindle cells, and fibrous tissue. The 
round and spindle cells develop into fibrous tissue, which thickens the 
septa and compresses the alveoli. There is also free production of new 
vessels, so that the new growth is very vascular. The area of lung thus 
affected varies. Usually the disease extends over a part of a lobe, or even 
a whole lobe. Besides the diffused form, gummata are seen sometimes in 
the lungs. These are rounded well-defined masses, few in number, usually 
of the size of a nut, and yellowish-white or gray in colour. They are firm 
at the circumference, but get softer in the centre, and the interior may be 
reduced by fatty degeneration to a puriform matter. Microscopic ex- 
amination shows the alveolar walls to be infiltrated at the circumference 
of the tumour with nucleated cells, while nearer the centre round or oval 
cells are seen in a finely reticulated tissue. These two forms of the same 
lesion are seldom seen, except in dead-born or very young infants. 

The liver may be affected, and, according to Dr. Parrot, is most fre- 
quently found diseafed in infants who die six weeks after birth. The or- 
gan is enlarged and hardened, and may be the seat of a sclerosis, diffused, 
as in the lungs, or, more rarely, of the circumscribed form. According tc 
G abler, who first drew attention to this condition, the organ in the dif- 
fused fibroid change is hypertrophied, globular, hard, and elastic, and its 
edges are rounder than in health. It creaks on section, and the cut sur- 
face is pinkish-white or yellow, and shows layers of small, white, opaque 
grains on a yellowish uniform ground. The capillary vessels are obliter- 
ated, and the calibre of the larger vessels is increased. These changes are 
due to the development of new fibro-plastic tissue which compresses the 
hepatic cells, obliterates the vessels, and checks or prevents secretion of 
bile. Gummata may be combined with the preceding, and are seen as 
circumscribed nodules embedded in healthy tissue. The masses are bright 
yellow, and present under the microscope the usual round or oval cells. 
There is commonly more or less softening in the centre, while at the cir- 
cumference the normal hepatic cells, between which the infiltration is ad- 
vancing, become hypertrophied. 

The spleen is often enlarged, and, according to Dr. Gee, if the enlarge- 
ment is great the child will probably die. Dr. Gee considers the degree 
of enlargement to be an index of the severity of the cachexia. If the child 
improves the size of the spleen does not diminish as the other symptoms 
disappear, but continues unaltered — often for years. In the spleen, as in 
the other solid organs, the disease consists principally of a diffused inter- 
stitial hyperplasia. 

The heart and lungs may be also affected. Gummata have been found 
in the former organ, and Dr. Coupland has described a specimen in which 
the muscular walls were thickened and hardened, and showed under the 
microscope an almost universal infiltration of small round cells amongst 
the muscular fibres. In the same case the kidneys, although normal to 
the eye, were seen to be undergoing similar chauges, and their substance 
was unnaturally firm. 

The thymus gland is seldom diseased. Sometimes collections of mat- 
ter are found scattered through its interior, but it is not clear that these 
are the consequence of the syphilitic taint. 

The suprarenal bodies are said by Virchow to be frequently the seat 
of a fatty degeneration. Hiiber has described a condition in which these 



206 DISEASE IN CHILDREN. 

bodies are large, grayish on the outside, translucent, and thick, with nu- 
merous white, irregular spots dispersed through their substance. 

The bones are often the seat of profound structural disease. Our 
knowledge of the bone disease which occurs as a consequence of inherited 
syphilis is only of recent origin. Dr. G. Wegner was the first to describe 
these lesions, and attribute them to their true cause, in 1870. More re- 
cently Drs. Parrot and Cornil have laboured at the same subject. Dr. 
Taylor, of New York, who has collected many cases of his own and analysed 
those of others, gives a graphic account of these affections in his well- 
known volume. 

Disease of the osseous system is a far from uncommon lesion. Accord- 
ing to Dr. Abelin, of Stockholm, it is found in ten per cent, of the cases. 
The bones especially affected are the long bones of the limbs ; next come 
the bones of the skull, the ribs, the scapulae, and the iliac bones. In the 
long bones there are two chief varieties. One begins with the periosteum 
— periosteogenesis: the other is not connected with the periosteum, but 
is confined to the ossifying line of the diaphysis — osteochondritis. 

Periosteogenesis begins as a periostitis. Parrot divides it into two 
forms : the osteoid and the spongioid or rachitic. Tire former may occur 
from the earliest period of life ; the latter is rarely seen in infants of less 
than six months old. 

In the osteoid form we find one or more layers of a new growth which 
is composed of interlacing trabecule lying perpendicularly to the axis of 
the shaft. The periosteum is thickened and adherent to the growth, and 
the latter has a chalky appearance from copious infiltration with calcareous 
salts. Consequently it is whiter and more friable than the bone beneath, 
and the line of junction is well defined. The osteoid material is found on 
the shafts of the long bones and on the cranial bones. In the latter situ- 
ation it may reach an inch or more in thickness. By the microscope we 
find differences in structure from true bone. There are no bone cor- 
puscles regularly disposed round the Haversian canals ; instead, corpuscles 
— three-sided or polygonal, resembling the stellate corpuscles of connec- 
tive tissue — anastomose by their processes with the cells of the periosteum, 
with corpuscles in the medullary spaces, and with one another. 

In the spongioid form, which is not seen in children under six months 
of age, a new fibroid tissue, pearly gray or yellowish in colour, is formed 
between the periosteum and the bone. It is more vascular than normal 
osseous tissue. 

The osteoid and spongy growths are often combined. If the new ma- 
terial consist of several layers, some may be more trabecular, others more 
spongy in structure — the chalky layer being nearer the bone, the fibroid 
immediately beneath the periosteum. While this process is going on 
around it, the shaft of the bone may be unaltered. This is usually the 
case in very young babies. In older children the calcareous matter of- the 
shaft may become absorbed, and the tissue be separated into layers by 
the formation of furrows filled with medulla. The bone as a consequence 
becomes light, porous, and brittle. The ends of the bones are thickened, 
partly by the periosteogenetic growth, partly by granulations thrown out 
from the spongioid tissue of the shaft. 

Osteochondritis appears to consist in a suppurative ostitis affecting the 
epiphyseal end of the bone. The layer of cartilage preparing for ossifica- 
tion becomes thickened to three or four times its natural width, and gets 
transparent and soft. This increase in width is due to excessive prolifera- 
tion of the cartilage cells, which assume much the shape and size of the 



INFANTILE SYPHILIS — MOKBLD ANATOMY. 207 

round granulation cells of syphilitic gummata. At the same time the 
intercellular substance is diminished. The cartilage which is actually 
undergoing ossification is thickened, and shows on section a broad wavy 
line. By the microscope the osteoblasts are found to be replaced more or 
less completely by small granulation cells or spindle-shaped elements. 
After a time destructive changes set in in the bony tissue. Dr. Parrot de- 
scribes a " gelatiniform softening," in which the bone is replaced by a soft, 
rather transparent material of a yellowish or brownish colour. After 
death, when the bone is dry, a cavity is left. The cancellous structure is 
also infiltrated with purulent watery fluid, so that the lamellse disappear 
and leave a fibro-vascular network filled with the same fluid. According 
to Wegner, a characteristic feature of this osseous disease is the protru- 
sion of bundles of fibrous tissue along the course of the blood-vessels. 
These bundles pass through the cartilage, the calcifying layer, and the 
processes of spongy bone, and j>enetrate deeply into the cancellous tissue 
of the shaft. 

As a consequence of this lesion the epiphyses with the ossifying layer 
may separate from the shaft of the bone. Suppuration is then set up, an 
abscess forms, and the pus escapes into the surrounding tissue by penetrat- 
ing the periosteum. The joint itself is not involved as a rule ; but Dr. 
Lees has reported a case in which the left elbow-joint and both knee-joints 
became filled with pus. 

Periosteogenesis is more common than osteochondritis. It attacks par- 
ticularly the humerus and the tibia ; and gives rise to symptoms, recog- 
nised during life, which will be afterwards described. 

An osseous lesion, due probably to changes similar in character to 
those described above, and called dactylitis, may attack the bones of the 
hands and feet. Dr. Taylor, of New York, has contributed much to our 
knowledge of this affection. According to this author, the disease begins 
either in the fibrous tissue surrounding a joint or in the periosteum. In 
the first form slight enlargement is seen of one or more toes or fingers — 
either of the whole length, as occurs in the toes, or of one or more pha- 
langes, as is seen in the case of the fingers. The process is slow and is 
accompanied by little or no pain, although the swelling interferes with the 
play of the joint. The second form is most frequently seen in the fingers. 
One or more of the phalanges becomes evenly rounded or fusiform. 
When the first phalanx is attacked, it usually assumes the shape of an 
acorn. The metacarpal and metatarsal bones may be also affected in the 
same way. In all cases, as a rule, the tendency is to resolution. Still, 
sometimes, if the enlargement is great, the part is exposed to accidental 
injury. The skin then becomes swollen, red, and tense ; ulcerates or is 
incised, and discharges a soft, cheesy detritus mixed with pus. Limited 
necrosis may follow and lead to shortening of the finger. Dactylitis is 
usually seen in very young children, but it may be a later symptom. The 
number of fingers affected varies. Dr. Taylor mentions a case in which 
all the phalanges of both hands were involved. 

The bones of the skull may be affected by the two forms of disease 
which attack the long bones. Gelatiniform softening is comparatively 
rare, but is sometimes found in very young infants. It begins beneath the 
pericranium but does not penetrate deeply into the bone, so that it rarely 
reaches the dura mater. After death the bone has a worm-eaten appear- 
ance. This form cannot be diagnosed during life. The osteoid growths 
are only found in older children. At first they always occupy the same 
situation, viz., the frontal and parietal bones surrounding the anterior fon- 



208 DISEASE IN CHILDKEN. 

tanelle. Sometimes they are also seen in the temporal bones, but are 
never found, unless the disease be exceptionally severe, in the orbital 
plates or the occipital bone. As they grow they produce- a very character- 
istic deformity of the skull. The fontanelle comes to be surrounded by 
four elevations, which are separated by two furrows intersecting one another 
in the form of a cross — the one transverse, the other antero-posterior. 
These osteophytes are usually spongy and porous, but they may become 
hard and smooth like normal bone tissue. They sometimes reach an inch 
and a quarter in thickness. 

In addition to the above purely syphilitic changes, local thinning of the 
bone, called cranio-tabes, is often found. This condition, which is a thin- 
ning or even perforation in certain spots of the cranial bones, was until 
lately considered to be exclusively a symptom of rickets. It is due to di- 
rect pressure upon the bones of the skull by the brain within and the 
pillow without, and is found especially in the occipital bone. It may be 
present in rickets where no trace of syphilis can be discovered, but is most 
common in cases where there is a distinct syphilitic taint. 1 

It is difficult to say with certainty at what age a child becomes liable to 
syphilitic disease of bone. Gelatiniform softening and osteochondritis 
generally occur early, beginning before the sixth month, and it is probable 
that they may even be present in intra-uterine life. Dr. Taylor has most 
frequently seen osteochondritis about six weeks after birth. The changes 
in the cranial bones seem to be later symptoms, and to occur most com- 
monly after the second year. In some cases reported by Drs. Barlow and 
Lees the ages of the children were between two and three years. Bone 
changes usually occur in the most severe cases, although it is said that 
they are sometimes the only symptom of the disease. If the patient re- 
covers, all traces of the morbid growth may disappear, but it is not rare 
to find curvatures or twists left as evidence of the cachexia which has 
passed away. 

Symptoms. — The first manifestation of the constitutional taint may oc- 
cur early or late, according to the degree to which the system is affected by 
the virus. When the syphilitic poison is very active, the disease may first 
show itself during intra-uterine life. The foetus then dies and is born dead 
before the proper time. Syphilis is thus a common cause of miscarriage ; 
and in all cases where premature labour is found to have occurred repeat- 
edly, we should not fail to make inquiry as to the previous health oi the 
parents. If examination of the aborted foetus be made, the bones and in- 
ternal organs exhibit signs of being profoundly affected by the syphilitic 
poison. 

In a less active state of the virus the child, although diseased, may be 
born alive. He is then much emaciated and looks shrivelled. His body is 
covered with an eruption of pemphigus which extends even to the palms of 
the hands and soles of the feet. He snuffles and has a hoarse cry. If, as 
generally happens, the internal organs are extensively diseased, the child 
dies. If no disease of the internal organs be present, the child may linger 
for a longer time, but he generally dies in the end. It is only in very rare 
cases that he struggles on and eventually recovers. 

Usually when a syphilitic child is born alive, he has at first a healthy 

1 Out of one hundred cases of cranio-tabes collected by Drs. Barlow and Lees, in 
forty-seven there was satisfactory proof of syphilis, in forty there was more or less 
evidence of the disease, only in twelve was there no indication of syphilis to he de- 
tected. 



INFANTILE SYPHILIS — SYMPTOMS. 209 

appearance. After a time — often between two and six weeks, rarely after 
three months — the first signs of the disease appear. Before this, however, 
the child in many cases has an unhealthy look, although it is difficult to 
say in what this unhealthiness consists. There is often great restlessness ; 
and the infant may sleep badly at night, sometimes breaking out into 
paroxysms of violent crying, which are a source of great perplexity and dis- 
tress to his attendants. It seems probable that this symptom is due to 
nocturnal pains in the bones, such as often affect adults before the outbreak 
of constitutional symptoms. The sleeplessness soon ceases under the in- 
fluence of specific treatment. Sometimes the outbreak of the general symp- 
toms is determined by a febrile disease, such as vaccination or one of the 
exanthemata. Thus, it is not very rare to see the rash of measles subside 
leaving the syphilitic eruption in its place. 

Snuffling is one of the earliest symptoms. It should always be inquired 
for, as while the child is breathing through the mouth it is not noticed, and 
the mother attributing the symptom to a cold may not think it deserving 
of mention. The snuffling is most evident when the child takes the breast, 
and his manner of doing so is very characteristic. Each breath is drawn 
with difficulty through the nostrils, and if the obstruction is great respira- 
tion has to be suspended while the babe sucks. Consequently, he can only 
draw the milk by short snatches. After every two or three mouthfuls 
he is forced to desist, and can be seen lying with the nipple in his half open 
mouth so as to renew his supply of air before he begins again. A discharge 
from the nostrils soon appears. This is at first watery, but soon becomes 
thicker and forms crusts which block up the nasal openings. Little ulcera- 
tions and cracks are generally seen about the nostrils and upper lip, due 
either to mucous patches or to scalding by the irritating secretion from the 
nose. In bad cases ulceration of the Schneiderian membrane may take 
place, and the septum is sometimes perforated. Occasionally, necrosis of 
the nasal bones follows, and fragments of the bones may be found in the 
dried discharge. The bones may be also loosened so that the bridge of the 
nose is flattened and sinks down. 

Another early symptom is the rash. This appears, as a rule, shortly 
after the beginning of the coryza. It is seen as flattened, slightly elevated 
spots, of a rusty red or coppery colour, scattered over the perinseum, upon 
the genitals, and around the anus. Sometimes it begins as a uniform, dingy 
red blush covering the belly, the perinseum, and the buttocks. It soon 
assumes the tint of the lean of ham ; its edge is distinctly circumscribed, 
and at the circumference isolated spots are seen of the same colour. The 
eruption is not confined to the lower part of the body. It is often seen in 
the folds of the joints, particularly of the armpits, along the sides of the 
neck, and over the chin. Other varieties of eruption are also seen. Ectky- 
matous and tubercular spots are not uncommon, and mucous patches and 
ulcerations are constantly present on the skin. The ecthymatous pustules 
are met with in th'e more weakly children. They are generally covered with 
a thick scab, under which the skin may ulcerate into deep, sharply cut sores. 
Mucous patches he at the outlets of the various passages opening on to the 
surface of the body, and in other places where the skin is especially delicate 
and moist. Thus they are seen around the anus, and in a girl round the 
vulva ; also about the commissures of the lips, and between the fingers and 
toes. They are round or oval patches, slightly elevated. The surface is of 
a grayish colour and is moistened by constant secretion. On a mucous 
membrane they quickly become converted into shallow ulcers. Ulcerations 
and cracks invade the angles of the mouth and alae of the nose. Thev are 
14 



210 DISEASE IN CHILDBED. 

linear and leave behind them linear cicatrices when they heal. The skin 
itself of a syphilitic child presents a very characteristic appearance. In 
severe cases it is dry, inelastic, and wrinkled in loose folds. The complex- 
ion is yellowish, and has been compared to weak cafe-au-lait. This tint is 
unequally distributed, being most marked on the prominent parts, as the 
nose, cheeks, forehead and chin. The general colour of the skin may be 
muddy ; but in children who survive it generally becomes singularly blood- 
less, and remains pale long after other symptoms have disappeared. 

The hair and eyebrows sometimes fall out. The nails may also be 
affected. Inflammation and suppuration occur in the matrix, so that the 
nutrition of the nail becomes impaired and the nail gets dry and is cast 
off. 

The cry of the infant is a noticeable symptom. It is hoarse and high- 
pitched from laryngeal catarrh or extension of the mucous patches to the 
larynx. Occasionally the hoarseness is accompanied by attacks of laryn- 
gismus stridulus. In almost every case the ossification of the cranial 
bones is delayed and the fontanelle is widely open ; but the growth and 
development of the teeth are not interfered with, for the teeth are cut 
early, as a rule, and with little inconvenience to the child. Cranio-tabes 
is present in the large majority of cases, and the posterior cervical glands 
are often enlarged. 

The bone disease presents many very characteristic symptoms. The 
long bones should be examined for signs of enlargement, especially the 
humerus, the femur and tibia. If we place the finger and thumb on the 
anterior and posterior aspect of the humerus at the upper part, and carry 
the hand downwards along the shaft, we shall often notice that the bone 
becomes thickened at the lower end, and that the thickening is greatest 
at the point of junction of the shaft with the epiphysis. In the tibia the 
thickening can be often detected on the inner surface, in the femur on 
the outer and inner aspects of the shaft. Besides these, there may be 
beading of the ribs and thickening of the radius and ulna above the wrist. 
The osteophytes on the cranial bones have already been described. 

When suppuration takes place outside the joint, especially if there be 
fracture of the neck of the bone, we find peculiar symptoms. The child 
appears as if paralyzed. His arms lie pronated by the sides of his body ; 
his legs are stretched out straight in the cot ; and when the patient is 
lifted up, they hang loose, like the legs of a doll, swaying from side to 
side. Crepitation can sometimes be detected between the shaft and the 
separated epiphysis ; and if an abscess forms, the joint, which had been 
tender before, becomes bent and stiff and exquisitely painful. Parrot has 
called this condition "syphilitic pseudo-paralysis." 

A form of real paralysis has been occasionally seen affecting the branches 
of the brachial plexus, and causing more or less complete loss of power in 
the arms. In two cases, described by Dr. Henoch, voluntary movement 
was almost completely lost in the upper extremities, the flexor muscles of 
the fingers alone retaining a slight trace of contractility. There were other 
signs of syphilis, and the paralysis disappeared under the influence of 
mercury. In some cases a peculiar twisting of the head backwards has 
been noticed when the child is placed in a sitting position. 

The degree to which the child is affected in cases of inherited syphilis 
varies — partly according to the virulence of the poison, and partly, also, 
according to the general strength of the infant. In rare cases, where twins 
are born of parents suffering from this disease, the two children may be 
affected very unequally. An instance of this came under my own notice. 



INFANTILE SYPHILIS — SYMPTOMS — EELAPSES. 211 

The children were three months old. One was much emaciated, with a 
shrivelled, parchment-like skin, covered with pemphigus. She snuffled 
and cried hoarsely. The other was a healthy-looking child, fat and strong, 
with a good complexion. She snuffled and showed on her buttocks signs 
of recent eruption ; but was never thought sufficiently ill to require medical 
advice. 

In practice we see every degree of intensity of the syphilitic cachexia. 
In one case, like the healthier twin just mentioned, the infant may be 
plump and strong-looking, with few symptoms and those trifling in char- 
acter. In another the child is wizened and wasted, with a wrinkled, 
inelastic, blotchy skin. He is peevish and restless, crying hoarsely and 
whimpering almost constantly. He is always hungry, for the state of his 
mouth and nasal passages offers a continual impediment to his drawing 
sufficient nourishment from the breast. He gets weaker and weaker — 
partly from disease, partly from want of food. VomitiDg and diarrhoea 
perhaps come on, and his miserable little life soon draws to a close. 

When the infant survives, he may seem quite to throw off all traces of 
his illness, and grows up a strong healthy child. But usually, when the 
symptoms have been severe, more or less permanent impression is pro- 
duced upon the system. The body may be stunted in growth ; the com- 
plexion earthy or unhealthy-looking ; the hair thin and brittle. The brain 
may be also more or less affected, and epilepsy, deficient memory, loss of 
perceptive power, and even gradually advancing imbecility are enumerated 
as consequences of the disease. 

Relapses. — In rare cases the symptoms of inherited syphilis are said to 
be delayed until the seventh, ninth, tenth years, or even later. Most of 
these cases are no doubt instances of relapse of the disease, the symptoms 
which occurred during infancy having been slight and transient. The 
relapse shows itself in coppery eruptions on the skin with discharges from 
the nose, ears, etc. The skin often ulcerates, and the nasal bones may be 
destroyed by gummy ostitis so that the bridge of the nose is depressed. 
The spongy bones and hard palate may ulcerate away, and the velum and 
pillars of the fauces may be destroyed so as to throw the nose and month 
into one cavity. The eyes may be affected with interstitial keratitis ; the 
permanent incisor teeth may be notched and dwarfed ; and deafness may 
occur. Deafness is the consequence, as a rule, of some morbid condition 
of the auditory nerve. It is seldom accompanied by any disease of the 
outer or middle ear, for there is tinnitus, and the patient cannot hear a 
tuning-fork placed on the head. It is most common between the fifth and 
fifteenth years, and can seldom be improved by treatment. 

Epilepsy has been mentioned as sometimes occurring in syphilitic chil- 
dren. It is usually one of the later symptoms, and may exist, as was seen in 
one of Dr. Hughlings Jackson's cases, without any sign of organic disease 
being detected in the brain after death. Syphilitic children sometimes 
die from a basic meningitis with symptoms similar to those produced by 
the tubercular form of the disease. They may also succumb to a cere- 
bral haemorrhage. Dr. Barlow has described a diffused thickening with 
opacity of the arterial coats in the brain as sometimes occurring in cases of 
inherited syphilis. This may lead to thrombosis of vessels or rupture of 
the artery with fatal hemorrhage. 

Lastly, in many children who have suffered from the hereditary form 
of the disease we may find amyloid degeneration of internal organs, espe- 
cially of the liver, the spleen, and the kidneys. 

Diagnosis.— When the symptoms are well marked the nature of the 



212 DISEASE IN CHILDREN. 

disease can scarcely be mistaken. The little, old-looking face, with its 
dusky complexion, its fissured lips and crusted nostrils ; the snuffling and 
hoarse cry ; the wasted body ; the wrinkled and inelastic skin ; the ham- 
like redness of the buttocks and perinaeuni — all these symptoms are suf- 
ficiently characteristic. Doubt is only permissible when the symptoms are 
few and indistinct, when nutrition is unaffected and the child has the 
appearance of fair health. In such cases there is general pallor of the skin 
and careful examination may detect a few coppery spots upon the body ; 
the spleen may be big, and we may, perhaps, discover some enlargement 
of the lower end of the humerus or shaft of the tibia. Chronic coryza is 
sometimes the only sign of the disease. Persistent snuffling in babies is 
commonly of syphilitic origin. If it be combined with pallor of the skin, 
specific treatment should always be adopted, especially if a history of pre- 
vious miscarriages can be obtained from the mother. 

In older children the signs of past disease are : Flattened bridge of 
the nose from long-continued swelling of the nasal mucous membrane 
when the bones are soft ; marking of the skin by little pits or cicatrices 
from former ulceration, especially when these are seated about the angles 
of the mouth ; protuberance in the middle line of the forehead between 
the frontal eminences from specific disease of the frontal bone ; enlarged 
spleen and marked pallor of the skin. If the permanent teeth have ap- 
peared the incisors should always be examined for signs of the charac- 
teristic malformations. 

In cases where there is enlargement of the ends of the long bones, the 
diagnosis from rickets has to be made. As compared with inherited syph- 
ilis rickets is a late disease. It rarely begins before the ninth month. 
The lesions of syphilis are seen early, almost always before the sixth month. 
Again, the bone disease in syphilis is usually evidence of a profound cachec- 
tic state. It is, therefore, in most cases accompanied by other and un- 
mistakable symptoms of the disease. Moreover, it is very partial, seldom 
affects the ribs, and is not symmetrical. In rickets it is always symmet- 
rical and general and the ribs are the earliest of the bones to be affected. 
In syphilis separation of the end of the bone and suppuration around the 
joint are not uncommon. In rickets these lesions are never seen. Again, 
the preliminary symptoms of rickets are very characteristic, and are quite 
wanting in an uncomplicated case of inherited syphilis. If, in any case, we 
find that the bone lesions are symmetrical and involve the ends of all the 
long bones, if there is an absence of the signs of inherited syphilis but 
a history of the symptoms characteristic of the early stage of rickets, and 
if we find that the child's dentition is backward, and that at ten months old 
he is showing no disposition to "feel his feet" — we shall have little diffi- 
culty in reaching the conclusion that the case is one of rickets. Still, a 
mild form of rickets is sometimes engrafted upon a syphilitic constitution. 
Here we shall find symmetrical and general enlargement of the joints 
and beading of the ribs combined with some of the symptoms of present 
or past syphilitic disease. 

Dactylitis occurring in syphilitic children must be distinguished from 
the necrosis which sometimes attacks strumous subjects. In syphilis the 
diseased bone is evenly enlarged, and no inflammation in the integuments 
occurs unless the size of the lump exposes it to accidental injury. In the 
fibrous form, also, the swelling is indolent and painless, and although not 
quite symmetrical, as in the osseous variety, is distinguished by its little 
tendency to end in suppuration and abscess. In strumous necrosis the 
bone is enlarged unevenly and generally forms a lump on one side. This 



INFANTILE SYPHILIS— PROGNOSIS — TREATMENT. 213 

lump gets bigger, then softens and suppurates, adhesions take place with 
the integument, and finally the abscess opens and discharges cheesy pus. 
On exploring the abscess bare bone is found at the bottom of the cavity. 
In all these cases careful inquiry should be made for history or sign of 
syphilis in the patient or other children of the family. 

Prognosis. — The prognosis is serious in proportion to the intensity of 
the cachexia. The general condition is, therefore, of greater importance 
in counting the chances of a child's recovery than the severity of any par- 
ticular symptom. The degree of intensity of the cachexia may be esti- 
mated by the date of appearance of the first symptoms of the disease, and 
by the extent to which nutrition is interfered with. If the symptoms ap- 
pear during the first fortnight and the child progressively wastes, death 
may be anticipated with certainty. All intercurrent derangements which 
interfere with digestion and assimilation of food sensibly increase the 
gravity of the case. Thus, vomiting and diarrhoea, which rapidly reduce 
the strength of even a healthy child, must be looked upon as very serious 
complications. 

Disease of the internal organs or of the bones, as they indicate pro- 
found contamination of the system, make the case a very anxious one. 
Moreover, the interference with function which results from the visceral 
disease is another reason for forming a very unfavourable opinion as to the 
result of the illness. 

There is one special symptom which must not be overlooked in forming 
a prognosis. This is the condition of the nasal passages. When these pas- 
sages are occluded from swelling and incrustation the child is forced to 
breathe through the mouth. Consequently, he can take but little nourish- 
ment, for while he sucks he cannot breathe, and while he breathes he can- 
not suck. The amount of food he takes is, therefore, very inadequate to 
the wants of his system, and he is in danger of actual starvation. 

If the disease first appears several months after birth, and if the child 
continues plump, and does not sensibly emaciate, the prognosis is favour- 
able even although particular symptoms may be severe. 

In cases of relapse, or of so-called delayed syphilis, when symptoms ap- 
pear after the seventh year, much depends upon the early recognition of 
the nature of the malady. Syphilitic lesions urgently require specific treat- 
ment, and the so-called tertiary forms of the disease cannot be neglected 
without serious consequences. Therefore, to look upon such lesions as 
scrofulous in their nature, to be treated with cod-liver oil and tonics, is to 
commit an error which may be a very fatal one to the patient. 

Treatment. — In every case where a woman gives birth to a syphilitic 
child the nature of the illness should be explained to the father, so that by 
suitable treatment of one or both parents their future children may be 
enabled to escape the disease. Treatment begun during pregnancy is often 
successful in preventing the taint from being transmitted to the foetus ; but 
it should be begun early and, if it can be borne for so long a time, should 
be continued for fully three months. 

In the child it is important to attack the cachexia at the earliest possi- 
ble moment. Therefore, if previous children have been syphilitic, and the 
parent in the interval have undergone no treatment, it is well to place the 
new-born child at once under the influence of remedies, even although he 
may have a healthy appearance and present no symptoms of the disease. 
Mercury is indispensable to the successful treatment of infantile syphilis. 
It may be either given internally or applied externally. In bad cases it is 
well to combine internal administration with external application, so as 



214 DISEASE IN CHILDREN. 

to bring the system as quickly as possible under the influence of the 
drug. 

The infant may be given one grain of gray powder twice a day, either 
alone or combined with a grain of carbonate of potash or a few grains of 
prepared chalk to prevent irritation of the alimentary canal. After a week 
the dose can be increased by a quarter of a grain every three or four days 
until two or three grains are taken twice a day. If the powders produce 
irritation of the stomach, they can be omitted for a day or two until the 
irritation has subsided. If they still disagree, it is better to change the 
preparation of mercury. In this case perchloride of mercury in doses of 
twenty or thirty drops of the ordinary Pharmacopoeia solution (gr. ^ to 
g Y . ^ ) can be given in a teaspoonful of water sweetened with glycerine 
two or three times a day. Children take this salt very well, and it will 
often agree when the gray powder excites irritation and vomiting. Calo- 
mel in doses of one-twelfth of a grain is sometimes preferred, but it is a 
more irritating preparation than the other. 

Externally, mercury can be employed in the form of the ordinary mer- 
curial ointment. The most convenient method of using this salve is to 
smear it inside the flannel band which covers the infant's belly. When 
this is done great cleanliness must be observed. The whole body must be 
washed well with soap and water every night so that all old ointment is 
removed before a fresh application is made. Another way of using mercury 
externally is in the form of mercurial baths. Thirty to ninety grains of the 
perchloride may be dissolved in two gallons of warm water. It is better to 
begin with the smaller quantity and gradually to increase the strength of 
the solution. The baths, besides their effect upon the general system, have 
a very beneficial local influence upon the cutaneous lesions. When the 
cachexia is very severe, it is well to combine external with internal treat- 
ment ; and in cases where there is great irritability of the stomach or 
bowels, we may be forced to depend exclusively upon the cutaneous ab- 
sorption of the remed} 7 . 

If a mother who is giving suck to her diseased infant be herself under- 
going treatment, it may be unnecessary in addition to give mercury to the 
child. Doubts have been entertained as to whether mercury is really se- 
creted by the breast. Cullerier has tested the milk of mercurialised moth- 
ers without finding evidence of the drug in the secretion. Still, it seems 
certain that an appreciable amount of the remedy must reach the child by 
this means, for in mild cases very rapid improvement is noticed in his 
symptoms while he remains at the breast. In cases of severity I am disin- 
clined to trust to the child's getting a sufficiency of the drug by this chan- 
nel, and prefer to supplement the treatment by the direct application of 
mercurial ointment to the abdomen. 

While specific treatment is being adopted, we must do our best to im- 
prove the general nutrition of the infant. The milk in syphilitic mothers 
is too often poor and watery, and ill-adapted for the supply of sufficient 
nourishment to their offspring. Therefore if the child wastes, especially 
if, by frequently requiring the breast and crying peevishly after his meal, 
lie seem to be ill-satisfied by the milk he has swallowed, it is well to give 
alternate meals of cow's milk diluted with an equal quantity of barley- 
water, and containing a small quantity of some malted food, such as 
Mellin's Food for Infants. If the child have a difficulty in sucking, on ac^ 
count of the condition of his nasal passages, this food must be given with 
a syringe. If a feeding-bottle be used, care must be taken that no other 
child be allowed to suck at the mouth-piece used for the diseased infant, 



INFANTILE SYPHILIS— TREATMENT. 215 

and the nurse should be cautioned not to put the teat into her own 
mouth. In connection with this subject it may be well to remark that it 
is a duty in all these cases to warn the nurses and servants in immediate 
attendance upon the child of the danger of infection from mucous patches 
and other discharging sores upon the patient's body. They should be di- 
rected to observe great cleanliness ; to avoid wiping their hands upon any 
cloth or towel used for the infant ; and if they have a finger wounded by 
any accidental cut or abrasion, on no account to handle the child unless 
the part is properly protected. 

The infant must be kept perfectly clean. His whole body should be 
bathed with warm water twice a day ; and if mercurial inunctions are being 
employed, soap should be used for the evening bath. Care must be taken 
to dry the child thoroughly after each washing. Fresh air is of the utmost 
importance, and if the patient be strong enough and the weather dry, he 
can be taken out every day warmly dressed into the air. 

Vomiting is best treated by suspending the mercurial for a few days. 
If the symptom continue and there be a sour smell from the breath, the 
diet must be altered, as recommended in such cases (see Infantile Atrophy). 
If looseness of the bowels occur and be not arrested by stopping the medi- 
cine, an alkali with tincture of catechu will usually check the derangement 
at once. Diarrhoea is seldom obstinate in these cases if the diet be regu- 
lated and the child's body be sufficiently protected from the cold. 

It is important to attend to the condition of the nostrils. All hard 
crusts must be removed by bathing with warm water after softening with 
cold cream. An ointment of the red oxide of mercury may then be em- 
ployed to the inside of the nostrils. Mucous patches must be well touched 
with the solid nitrate of silver, and if large ecthymatous crusts have 
formed on the body, they must be removed by poulticing. The uncovered 
ulcer can then be treated with the red mercurial ointment. 

Internal treatment must not be continued long after the symptoms of 
the disease cease to be noticed. On account of the profound anaemia often 
induced by the long-continued administration of mercurials it is wise to 
change the treatment as soon as the skin has recovered its healthy appear- 
ance, and the other specific symptoms have subsided. Cod-liver oil and 
iron can then be given. In addition, every care must be taken to promote 
healthy nutrition by judicious regulation of the diet, and vigilant attention 
to all the minor agencies which exert so material an influence upon the 
well-being of the infant. 



part 4, 
DISEASE OF THE DUCTLESS GLANDS AND BLOOD. 



CHAPTEE I. 

LEUCOCYTHEMIA. 



Leucocythemia (leukhnemia), although a rare disease in childhood, is oc- 
casionally seen in the young subject, and therefore may be shortly de- 
scribed. The disease is characterised by great excess of the leucocytes of 
the blood, enlargement of the spleen, sometimes of the lymphatic glands, 
and a morbid state of the bone medulla. Two cases have come under my 
notice, both in children under three years old. In each of these the malady 
assumed a febrile form, and was accompanied by enlargement of the spleen 
without an} r apparent affection of the lymphatic glands. In lymphadenoma, 
which is described elsewhere, an increase in the number of the white cor- 
puscles is exceptional. Sometimes, however, in that disease excessive over- 
growth of lymphatic elements is combined with multiplication of the colour- 
less blood-cells. These cases present a great resemblance to the lymphatic 
form of leucocythemia, and, indeed, anatomically appear to be almost in- 
distinguishable from it. In the present chapter the splenic form of 
leucocythemia will alone be described. 

Causation. — The etiology of leucocythemia is not clear. Out of 150 
cases analysed by Dr. Gowers in one-fourth there was a history either of 
ague or of habitation in an ague district. Of my own two cases, one had 
lived at Malta ; the other was a resident of London, but had lived in a 
street in which the roadway had been broken up for repairing and relay- 
ing drains ; and for two or three months the upturned soil, saturated with 
coal-gas and other unhealthy effluvia had remained heaped up by the side 
of the foot-pavement. The disease appeared shortly before the close of 
these operations, and I cannot but think that the illness took its rise in 
the offensive emanations to which the child had been constantly exposed. 

Morbid Anatomy. — The spleen is enlarged and may reach a great size. 
This increase is due to an overgrowth of the splenic pulp, the leucocytes 
and the fibrous stroma being equally increased. The organ, although en- 
larged, retains its normal proportions, so that its shape is not changed. Its 
density is increased and its colour is paler than natural. On the surface it 
is smooth unless local peritonitis have occurred, in which case particles of 



LEUCOCYTHEMIA — MORBID ANATOMY — SYMPTOMS. 217 

lymph, may adhere to the capsule. From this cause it may contract ad- 
hesions to parts in its neighbourhood. Its section is smooth and of a 
brownish-yellow colour mottled with paler streaks from thickened tra- 
becule, and but little blood escapes from it on pressure. The Malpighian 
bodies are not very prominent, and may be seen under the microscope 
to be the seat of fatty or lardaceous degeneration. 

The liver is often enlarged from congestion, and may be fatty. The 
kidneys, too, are often the seat of fatty degeneration. Hsernorrhagic ex- 
travasations are common, and may be seen in the skin, the heart, the 
lungs, the brain, and the retina, and fluid effusions may be found in the 
serous cavities. 

In some cases the lymphatic glands undergo slight enlargement, but 
the increase in size is rarely universal as it is in lymphadenoma. On 
examination they appear to be normal in structure without any hyperpla- 
sia of the reticulum, and suppuration or caseation rarely occurs. As in 
lymphadenoma, adenoid growths may be also found in the tonsils, the 
follicles of the tongue, the glands of the stomach and intestines, and in 
other situations. The capillaries in various parts are distended with col- 
lections of leucocytes. The marrow of the bones is more fluid than natural, 
is grayish in colour, and shows an accumulation of white and red corpus- 
cles. The blood itself is much altered. It is pale in colour, coagulates 
loosely, and shows an enormous excess of white corpuscles, together with 
a diminution in the number of the coloured cells. Consequently the rel- 
ative proportions, instead of being one white to four hundred and fifty red, 
as in health, may fall to one to twenty, one to ten, one to five, or even to an 
actual equality of number. The white cells may also present peculiar char- 
acters. They are sometimes seen of two quite different forms ; the one 
double the size of the other and full of small fat granules. According to 
Hosier, this larger form is evidence of morbid change in the bone medulla. 
After death thick creamy-looking clots may be found in the cavities of the 
heart, the terminal branches of the pulmonary artery, and the systemic 
vessels. 

Symptoms. — The illness begins insidiously. Sometimes at first the 
general health alone seems to be impaired ; sometimes even from the be^ 
ginning the belly is noticed to be large. The child loses his sprightliness 
and begins to look pale and to droop. His appetite fails and he slowly 
wastes. There is almost always more or less fever, but this is at first 
slight and occurs irregularly. Afterwards it becomes more continuous and 
the temperature rises to a higher level. 

Enlargement of the spleen, although not always noticed at an early 
period of the disease, is usually to be detected on careful examination. 
The limits of the organ should be always estimated by percussion as well 
as palpation. The degree of enlargement varies. In neither of my cases 
did the lower edge reach more than three fingers' breadths below the ribs, 
and there did not seem to be any great upward extension. In many cases, 
however, the increase in size is much greater. Some enlargement of the 
liver may also be noticed. 

When the disease is fully developed, the child is pale and weakly look- 
ing. His complexion is very white round the mouth and eyes, and at the 
sides of the nose ; but often there is a flush on the cheeks, which at times 
is noticed suddenly to disappear, leaving the face ghastly pale from the 
contrast. Often, especially when the disease is advanced, there is a pecu- 
liar sallow, half-jaundiced tint of the skin. This has been attributed to 
the anosmia, the altered blood being unable to destroy the bile pigment 



218 DISEASE m CHILDREN. 

absorbed into it from the intestine. The belly is usually swollen from flatu- 
lent accumulation, as well as from enlargement of the liver and spleen. 
No tenderness is noticed on pressure of the abdomen, but if the bone 
medulla is diseased, pains in the limbs may be complained of in walking. 
There is no loss of elasticity of the skin. The tongue is furred and the 
bowels are often capricious. Sometimes the stools are loose and slimy ; 
at other times there is constipation. The child may cough, and his breath- 
ing may be short ; but unless a complication be present, examination of 
the chest discovers merely a little large-bubbling rhonchus at the bases of 
the lungs. The pulse is quickened, especially at night. It is usually over 
100, sometimes considerably so. In one of my cases — a little boy aged 
two years and a quarter — the urine was high-coloured and offensive, and 
contained bile, but no albumen. There was some difficulty in holding it 
at night. 

The temperature rises in the evening to between 102° and 103°, sink- 
ing to 99° in the morning. The fever, however, is very irregular, and on 
some days is much higher than it is on others. The skin may be moist 
at night, and sometimes there is copious perspiration. An examination of 
the blood discovers a great excess in the number of the white corpuscles. 

As the disease goes on the child remains very fretful and pining. He 
sleeps badly at night and continues to lose flesh. His expression is very 
distressed, and his face is white and haggard. He is thirsty, but cares 
little for food. Often haemorrhages come on, and these effusions form a 
very characteristic symptom.* The nose may bleed, or blood may be dis- 
charged by the mouth or by stool. Although usually a late symptom, 
haemorrhage is not always delayed until near the close of the illness. 
Epistaxis is sometimes noticed quite early in the disease. 

Enlargement of lymphatic glands may occur, but this is rarely con- 
siderable in a case of pure splenic leucocythemia, and pressure signs from 
this cause are rarely noticed. Towards the end of the disease oedema and 
dropsical effusions are common. There may be ascites or hydrothorax or 
oedema of the lung, and the lower limbs may swell and pit on pressure. 

The fever usually perseveres to the end, and the child grows thinner and 
weaker. Various complications occur before the close, especially croupous 
pneumonia and pleurisy. Death is often preceded by an attack of convul- 
sions, due, probably, to obstruction of the cerebral capillaries by masses 
of leucocytes, as described by Bastian. 

Diagnosis. — The symptoms of leucocythemia are sufficiently character- 
istic of the disease. Irregular pyrexia and general impairment of nutri- 
tion, combined with a distressed, pallid face, a sallow complexion, a 
swollen abdomen, an enlarged spleen and liver, and the occurrence of 
epistaxis or melaena, point very distinctly to leucocythemia ; and the 
diagnosis is at once confirmed by a microscopical examination of the 
blood. 

When seen for the first time, the case often presents some resemblance 
to enteric fever ; and a haemorrhage occurring from the bowels might 
appear to confirm this view of the illness. But the history, which usually 
indicates disease of considerable standing, the complete absence of rosy 
spots, the enlargement of the liver as well as of the spleen, the peculiar 
sallow tint of the skin — these symptoms are very unlike typhoid fever ; 
and if at a late stage oedema of the lower limbs occurs, the presence of a 
symptom so uncommon in enteric fever should make us at least doubt the 
correctness of this diagnosis. An examination of the blood showing a 
large excess of leucocytes is of course conclusive. 



LEUC OC YTHEMIA — PROGNOSIS — TREATMENT. 219 

Leucocythernia may be diagnosed with certainty if, with an enlarged 
spleen, the proportion of colourless corpuscles is greater than one to twenty. 
In a doubtful case, therefore, it is well to count the corpuscles with the 
hteniacytometer. If the proportion of leucocytes is less than one to twenty, 
the case may still be one of leucocythernia in process of development ; and 
as Dr. Gowers has pointed out, to exclude this disease it will be necessary 
to make repeated examination of the blood, and satisfy ourselves that the 
proportion is not increasing. 

In cases where the lymphatic glands undergo hyperplasia, the disease 
is distinguished from lymphadenoma by noticing that the lymphatic en- 
largement is only moderate, and occurs as a late complication. Also that 
the excess of white corpuscles in the blood is very pronounced. In lym- 
phadenoma this increase is either absent or is comparatively insignificant. 
Composite cases are, however, occasionally met with, and may be a source 
of perplexity. 

Prognosis. — The disease invariably terminates fatally ; and the more 
nearly the number of the white corpuscles in the blood approaches to an 
equality with that of the red, the greater the prospect of an early termi- 
nation to the illness. Haemorrhage, unless it be from the nose, is a very 
grave symptom. 

Treatment. — No treatment has yet been discovered which is capable of 
arresting the progress of the disease. Arsenic, which is of great value in 
cases of lymphadenoma, has no influence in leucocythernia, and quinine, 
iron, and tonics generally have proved to be quite useless. Cod-liver oil 
may. however, be given, and is said to be sometimes of temporary benefit. 
In an early stage of the illness faradisation of the splenic region for fifteen 
minutes twice a day is said to diminish the proportion of white corpus- 
cles in the blood. In a case reported by Mosler this application, com- 
bined with the internal administration of piperine, oil of eucalyptus, and 
hydroch 1 orate of quinine, reduced the size of the liver and spleen and 
greatly improved the condition of the blood. Dr. G. V. Poore finds the 
size of the spleen to be diminished temporarily after faradisation, but 
states that the therapeutic benefit derived from the application is very 
transient. Many times a spleen which was felt to be smaller and softer 
immediately after galvanism was found after only a few hours to have 
recovered its former size and again become tense and hard. Dr. Poore 
states that the leucocytes in the blood are increased in number directly 
after the application. Injection of various substances into the spleen has 
been attempted, but the results have not been encouraging. A case is re- 
ported in which a grain and a half of salicylic acid was injected into the 
organ, and the patient died six hours afterwards. 

Excision of the spleen has been tried, but has invariably led to such 
effusion of blood that the death of the patient has very quickly followed. 
All we can do is to treat distressing symptoms as they arise, and to sup- 
ply the patient with such nutritious food as his stomach can digest. Quiet 
is very important when the anaemia is great. Looseness of the bowels 
must be treated with small doses of rhubarb and the aromatic chalk pow- 
der, or with dilute sulphuric acid ; oedema with digitalis and diuretics ; 
haemorrhage with the ordinary styptics. If the pain is complained of over 
the spleen, it is best relieved by counter-irritation and anodyne applications, 
such as smearing the surface with equal parts of the extract of belladonna 
and glycerine, covering the side afterwards with cotton-wool. 



CHAPTEK II. 

LYMPHADENOMA. 

Lymphadenoma (adsenia, lymphatic anaemia, Hodgkin's disease) is one 
of the less common diseases of early life, but it occurs sufficiently often 
to render the affection a not unfamiliar one in Children's Hospitals. Lym- 
phadenoma consists in a hyperplasia of lymphatic tissue in various parts 
of the body, even in situations where such structures do not normally 
exist in any great quantity. The lymphatic glands are chiefly involved, 
but the spleen, liver, and kidneys may be greatly enlarged and altered in 
structure. If the enlargement be limited to a few glands or organs, the 
disorder may have the characters of a local complaint. Usually, however, 
the affection spreads very extensively and exhibits all the phenomena of a 
general disease, being attended with fever, wasting, great and increasing 
pallor, and marked weakness. In the end it is almost invariably fatal. 

Causation. — The causes of lymphadenoma are obscure. Diathetic ten- 
dencies have been supposed to give rise to the disease, and there is no 
doubt that in some cases pulmonary consumption or syphilis has been 
noted in the parents. In other cases, however, the family history has 
been good. Acute disease in the child himself has sometimes appeared to 
be the starting-point for a slow deterioration of health which has event- 
ually developed into undoubted lymphadenoma. So also the occurrence 
of the illness has been attributed to bad or insufficient food or insanitary 
conditions generally. In some cases, however, no sufficient cause has 
been discovered to account for the failure of health. The disease, like 
tuberculosis, with which it presents certain affinities, may develop without 
apparent reason in a child whose health had previously given no cause for 
anxiety. 

In not a few cases some local derangement or injury has appeared to 
be the exciting cause of the enlargement of the lymphatic glands. Thus 
a decayed tooth, a patch of eczema, an otorrhcea — all these have been 
known to be quickly followed by a swelling of the glands in the neighbour- 
hood of the irritant. In scrofulous subjects a persistent caseous enlarge- 
ment of glands from this cause is not uncommon. In lymphadenoma, 
however, the morbid changes do not remain limited to the neighbourhood 
of the irritant. Others more distant from the seat of irritation take on 
the same unhealthy action, and thus the disease spreads widely so as to 
involve adenoid tissue in all parts of the body. 

The age of the children affected is usually four or five years and 
upwards. I have, however, seen a well-marked case in an infant eight 
months old, who had begun to suffer at the age of three and a half 
months. 

Morbid Anatomy. — After death in a case of lymphadenoma we usually 
find great enlargement of the lymphatic glands, and often of the spleen, 
the liver, and the kidneys. In addition there is commonly overgrowth of 



LYMPH ADENOMA — MOKBID ANATOMY. 221 

the more minute collections of adenoid tissue in various parts of the bod}-, 
as in the tonsils, the pharynx, the gullet, the stomach and intestines, etc. 
Of these the more considerable enlargements are often limited to a com- 
paratively few organs and structures, but microscopical examination dis- 
covers ve^ wide-spread changes in parts which present little or no apparent 
alteration to the unassisted sight. 

The lymphatic glands are greatly enlarged, and the enlargement may 
be in two forms — a hard and a soft swelling. This difference appears 
to depend less upon the nature of the growth than upon the rapidity of 
its progress, for the two varieties may be found combined in the same 
subject. 

The size of the swollen glands commonly varies from a hazel-nut to a 
hen's egg, but in exceptional cases the growth may reach still more con- 
siderable dimensions. The first glands to be affected are usually those in 
the neck. Then follow in order of frequency the axillary, inguinal, retro- 
peritoneal, bronchial, mediastinal, and mesenteric. But besides enlarge- 
ment of glands, circumscribed growths may be developed in spots where, 
although adenoid tissue exists normally in small quantity, it is not col- 
lected into glandular masses. By this means the various groups of enlarged 
glands may be found connected together by chains of newly developed, 
lymphatic nodules. 

When a group of glands takes on the morbid process, the individual 
bodies at first remain distinct and are movable. As the disease progresses 
they cease to be movable, and eventually become welded together into a 
solid mass. The process of union consists in a disappearance of the cap- 
sule, which becomes pierced and ultimately almost destroyed as the new 
lymphatic tissue accumulates. On examining such a mass the outline of 
diseased glands can be recognized here and there by a thin fibrous capsule, 
but the confluence is for the most part complete, and no intervening infil- 
tration can be discovered. On the surface the mass is often very irregular 
and nodulated, and may be mottled with white or yellow patches, but 
caseation is seldom seen. If the mass be superficial it may be adherent to 
the skin. In rare cases it suppurates. The greater or less hardness of the 
enlarged gland is determined, as has been already said, by its rapidity of 
development. If it grows very quickly the gland is soft. On section of 
such a gland the substance appears often to be almost diffluent. If firmer, 
it yields a creamy juice when scraped. If very firm the hardness is found 
to be due to hyperplasia of the fibrous stroma, dense bands of fibrous tis- 
sue running in various directions through the mass. 

Under the microscope the morbid change in the glands is seen to con- 
sist in an enormous increase in the lymph corpuscles. These accumulate, 
and by their pressure may perforate the capsule and even split up the 
septa and cause them to disappear. In the softer growths the diseased 
process is chiefly of this kind. In the firmer glands there is an increase in 
the fibrous stroma, which becomes greatly thickened. The hypertrophy 
may even obliterate the meshes of the reticulum and convert the organ 
into a mass of fibrous tissue. 

The spleen commonly suffers, especially if the disease begins in the 
lymphatic glands of the neck. The organ becomes greatly enlarged. Its 
normal lymphatic tissue takes on a rapid growth, and shows the same ten- 
dency to fibrosis that is noticed in the glands. Externally the organ is of 
a dull reddish colour with paler patches, and yellow spots from the size 
of a mustard-seed upwards are often seen scattered over the surface. To 
the touch it is usually dense and firm. On section whitish or yellow nod- 



222 DISEASE IN CHILDREN. 

riles are discovered on a dark-red ground. The nodules are more or less 
closely aggregated so as to form masses of varying size and shape. The 
new material appears to originate in the Malpighian follicles and the peri- 
arterial sheaths of lymphoid tissue. It is composed of lymphoid cells and 
large quantities of imperfect fibrous tissue. The fibrous stroma is often 
thickened, and may show bands of fibrous tissue without definite arrange- 
ment, or running loosely parallel so as to form oval loculi by their diver- 
gencies. In a late stage the bands are sometimes pigmented at their" 
edges. Under the microscope these bands appear to be formed by rapid 
induration of a lymphatic tissue growing around the vessels. 

In the liver the new growth usually appears in the form of small, irreg- 
ular, infiltrating masses which may project as irregular prominent patches 
on the surface. The structure of these growths is similar to that of the 
new material in other parts, but in this organ there appears to be a greater 
tendency to caseation. The lymphatic new growth occupies the interlobu- 
lar spaces. In a case reported by Dr. Greenfield it seemed to start in the 
portal canals as small masses w T hich extended around and into the lobules, 
the liver-cells becoming degenerated and shrivelled. 

When the kidneys are affected the organs are enlarged and often irreg- 
ular in shape. Their colour is light yellow or even dull white, and ecchy- 
moses may be scattered over the surface. Sometimes signs of more profuse 
haemorrhage are found, and large purple blotches are seen through the 
capsule on the pale surface of the gland. On section the cortical substance 
is more or less swelled, and is of a yellowish-white colour mottled with 
points and patches of red. By the microscope an excess of adenoid tissue 
is seen between the tubules, sometimes separating them widely. The 
growth is collected in large quantities around the glomeruli, and in some 
cases the new tissue appears to pass along the vessels into the interior of 
the Malpighian capsule. In both liver and kidneys it is common to find 
blood-vessels blocked by masses of colourless corpuscles. 

The new growths developed in places where adenoid tissue exists nor- 
mally in minute quantity are usually rather soft and elastic. They are of 
a pinkish colour and very vascular. Such local developments of lymphatic 
tissue may be seen in the tonsils, at the back of the pharynx, and in the gul- 
let, stomach, and intestines, originating in the follicular glands. All these 
often undergo ulceration. Growths have also been found in the testicles, 
peritoneum, omentum, pleura, and in the lungs. In the latter situation 
they often break down and form cavities. 

When the blood is examined microscopically the red corpuscles are 
seen to be very pale in colour, but they usually form rouleaux in the or- 
dinary manner. Amongst them are corpuscles of much smaller diameter. 
The red corpuscles are considerably reduced in quantity, but there is sel- 
dom any material addition to the number of white corpuscles : indeed, in 
many cases, like the red cells they are diminished in number. Sometimes, 
however, the leucocytes may appear to be slightly more numerous than in 
the healthy subject ; but even if the spleen be greatly enlarged, no increase 
sufficient to constitute leucaemia is observed in cases of true lymphade- 
noma, and the white cells never present the altered characters which are 
noticed in the former disease. As a rule, a greater excess of white corpus- 
cles is seen in cases where the lymphatic growth is of the soft variety than 
where it is hard and chiefly fibrous. Forms of mixed disease are also 
sometimes met with in which there is increase in quantity of the splenic 
pulp. The affection has then some of the characters of leucocythemia. 

Symptoms. — The symptoms of lymphadenoma may be divided into 



LYMPHADE^OMA — SYMPTOMS. 223 

those proper to the illness, which may be called the regular symptoms, 
and those which are irregular and accidental, being the consequence of the 
pressure set up by the growths upon the parts around. 

The regular symptoms consist of the general constitutional disturbance 
excited by the disease, the changes in the state of the blood, and the pres- 
ence of enlarged lymphatic glands. 

The general constitutional symptoms may precede or follow signs of 
enlargement of glands. They consist of a febrile movement more or less 
high, with gradually increasing wasting, pallor, and loss of strength. 

A little boy, aged three years, was under the care of my former col- 
league, Dr. Mitchell Bruce, in the East London Children's Hospital. The 
child had been ill and languid for three months before admission, gradu- 
ally wasting and suffering from occasional attacks of diarrhoea. When 
brought to the hospital he was weakly, with a pale complexion and hag- 
gard, anxious look. His face often flushed up suddenly ; his skin gener- 
ally was harsh and dry. At first no special disease of organs could be 
discovered. The spleen could be felt projecting about half an inch below 
the ribs, the liver was normal in size, and no enlargement of the lym- 
phatic glands was noticed. The boy coughed occasionally, but the phys- 
ical signs about his chest were normal. His temperature on the first 
evening was 101.4°, and continued to stand at much the same level for 
some time. It sometimes sank to 99° and at other times rose suddenly 
for a few hours to 101°, but it usually varied between 100° and 101°. The 
boy continued in much the same state, being usually apathetic and dull, 
although he brightened up a little at times and would play listlessly with 
his toys. The course of the illness was very variable, and the child seemed 
much worse at some times than at others. Once or twice he seemed 
decidedly better and regained a few ounces of his weight, then he relapsed 
and wasted, rapidly losing a pound and a half in a week. Often he was 
drowsy, and his appetite was always poor. 

As time went on the liver and spleen became moderately swollen, signs 
of enlargement of the bronchial glands were noticed, and deep pres- 
sure in the abdomen discovered some enlargement of the mesenteric 
glands. 

The bowels remained more or less loose. The boy grew slowly weaker, 
and died after a residence of four months and a half in the hospital. 
There was never any oedema of the limbs, and the glands in the neck were 
not affected. 

On examination of the body after death, large yellow, cheesy-looking 
masses were found adherent to the under surface of the breast-bone, and 
the anterior mediastinum was filled with a large mass of agglutinated 
glands. A similar mass was found in the abdomen in front of the spine 
just below the diaphragm and surrounding the head of the pancreas. The 
liver was large, soft, and flabby to the touch. Its section showed a half 
translucent appearance, and on close inspection this was found to be due 
to a multitude of closely set little masses, the size of a pin's head or less, 
some clear and transparent, others more yellow. The spleen also was 
large, and its section showed the appearance usually noticed in this disease 
and which has been already described. Both lungs were found on section 
to be pervaded with small masses of new adenoid growth. 

In this case the general symptoms preceded the signs of local mischief. 
Often, however, especially if the illness begins, as it commonly does, with 
enlargement of the cervical glands, the affection has at first the characters 
of a local disease. But sooner or later, as the lymphatic tissue becomes 



224 DISEASE IN CHILDREN. 

more and more involved, the patient begins to suffer from irregular fever 
and grows very decidedly anaemic. 

The glandular swellings in the neck usually form an irregular nodular 
mass which may extend from one side to the other, passing underneath the 
chin, or may be limited principally to one side. At first the individual 
glands can be made out, and the masses are movable. Afterwards the glands 
become more welded together and the masses are fixed. The swellings are 
painless, and unless of very rapid growth are dense and firm to the touch. 
In some cases a mass of enlarged glands will become very soft and suppu- 
rate, forming an abscess which discharges and heals up in the ordinary 
manner. Besides the neck, enlarged glands may be felt in the axillre and 
groins. In the armpits the size of the growths may interfere with the 
movements of the arms. Examination of the chest and belly often dis- 
covers a similar change in the glands lying in the anterior mediastinum 
and abdomen. The enlargement of the liver and spleen is usually mod- 
erate, although sometimes — especially in the case of the latter organ — it 
may be very considerable. 

While the disease is limited to swelling of a few glands in the neck, 
the child, although pale, may be active and cheerful, apparently suffering 
in no way except from the local inconvenience. When, however, the 
glands grow rapidly, or the disease spreads from the neck to other parts 
of the body, constitutional symptoms begin to be noticed. Fever is almost 
invariably present, although in the earlier stage it is slight and intermittent. 
In the cachectic stage the temperature often rises to a high level, and 
for a few days together may range between 103° and 105°, sometimes even 
passing the higher limit. Sweating is not common ; indeed, in most cases 
the skin is excessively harsh and dry. The digestive organs almost inva- 
riably suffer. The tongue is covered with a white fur, and the papilla? are 
prominent and red. Ulcerative stomatitis may be present on the inner 
side of the cheek. The appetite is poor and indigestion and vomiting may 
be complained of. The bowels are sometimes costive, but often they 
are loose, and the dejections may be preceded by griping pains in the 
belly. The looseness is due in many cases to small ulcerations of the ileum. 
There is then usually abdominal swelling, increased tension of the parie- 
ties, and tenderness on pressure. More or less cough is a common symp- 
tom, and an examination of the chest often discovers signs of consolida- 
tion and softening. These lesions commonly result from growths in the 
lung which soften and break down into cavities. 

Great apathy and dulness of mind are in many cases associated with 
the cachectic stage of the disease. The child may be found to sleep almost 
constantly, his senses seem dulled, and his wants are so little pressing 
that he asks for nothing and makes no complaint. Indeed, sometimes it is 
most difficult to get him to speak at all. The urinary function is rarely 
interfered with, but sometimes blood is passed with the urine. In a case 
reported by Dr. Goodhart — a little girl aged ten months — the child's water 
towards the end of the disease became red with blood. 

The anasmia is usually extreme. The whole surface of the body is ex- 
cessively pale, and the mucous membranes are singularly bloodless. Pur- 
puric spots may be found on the body, face, and limbs, and sometimes 
larger dark purplish blotches are seen from more extended extravasation. 
Flushing of the face is a common symptom, and a redness of the cheeks at 
this time forms a curious contrast with the dead whiteness persisting round 
the mouth and eyes. A microscopic examination of the blood shows the 
diminution in the number of the red corpuscles which has been already 



LYMPHADENOMA — SYMPTOMS. 225 

referred to. The white corpuscles are rarely in notable excess. As a con- 
sequence of the anaemia oedema may occur in the limbs, and there may be 
ascites. Pressure of the enlarged glands upon the venous trunks may also 
aid in the production of serous effusion. 

A good example of the more common form of the disease, where the 
general constitutional disturbance occurs subsequently to the primary 
glandular enlargement, was seen in the case of a little boy, aged thirteen 
years, who was under the care of my colleague, Dr. Donkin, in the East 
London Children's Hospital. The boy came of a healthy family and had 
himself been strong and healthy until the age of eight years, when he was 
laid up for three months in consequence of a fall on his head and spine. 
In this illness the lad could not rest on his back or side, but was obliged to 
he on his face. Although he began to walk again in two months' time, and 
was convalescent at the end of the third month, he never recovered his 
strength completely. Twelve months after his illness he was again laid 
up with pains in the chest and swelling of the face and arms. The swell- 
ing soon subsided, but the boy remained weak and complaining and was 
often under medical treatment. 

On admission the patient complained of lumps in his neck which he 
stated were of three years' duration. For three months he had been losing 
flesh and his belly had been growing larger. His skin, he said, had been 
dry for some time. His legs had never swelled, but he had noticed a swell- 
ing of his scrotum for three or four days. He was subject to cramp-like 
pains about the umbilicus which were often severe, and the belly at these 
times was tender. He had had a cough for a month without expectoration, 
and his bowels had been relaxed for a week. 

On examination the boy was found to be very thin, and his skin was 
dry, rough, and furfuraceotis, especially about the belly. The cervical and 
submaxillary glands were enlarged on both sides so as to form a collar 
round the neck. The axillary and inguinal glands were normal. No en- 
largement of the liver or spleen was noticed. The abdomen was distended, 
with fulness of the superficial veins. There was some tenderness on 
pressure below the umbilicus, and the tension of the parieties was in- 
creased. No growth could be felt in the belly, and there was at first no 
ascites. There was some oedema of the scrotum, but none of the arms or 
legs. The tongue was red and rather raw-looking, and some superficial 
ulceration was noticed at the angles of the mouth and inside the left 
cheek. The bowels were relaxed, the stools being loose and lightish yel- 
low in colour. There were signs of consolidation of the right lung. The 
urine was pale, slightly alkaline, but contained no albumen. An examin- 
ation of the blood showed the absence of any excess of white corpuscles. 

After admission the boy remained in a very apathetic state, and whether 
up or in bed seemed to be always drowsy. He would be found asleep 
with his head on his arms or curled up on a sofa. His face was habitually 
very pale, but at times it would flush up irregularly. He coughed occa- 
sionally, and expectorated tenacious mucus. His temperature was always 
high, rising at night to 103° or 104°. He continued to waste and grow 
weaker. Death was hastened by a severe attack of vomiting which pro- 
duced great prostration, and he died soon afterwards. 

After death the cervical, bronchial, retro-peritoneal, and mesenteric 
glands were found to be enormously enlarged, forming agglomerated 
masses in which, however, individual glands could still be made out. The 
enlarged glands were very tough. On section, the larger number were of 
Yellowish tint and seemed fibrous, but a few were grayish and translucent 
15 



226 DISEASE IN CHILDEEN. 

Some contained caseous matter. New growths very similar in appearance 
were found in the pleura and peritoneum. There were some ulcers in the 
ilium and caecum. The follicles of the tongue were swollen. Both tonsils 
were large and ulcerated. Small ulcers were found on the anterior wall of 
the trachea ; and on the posterior surface of the epiglottis were yellowish 
infiltrations of a roundish shape. All the mucous membrane in this neigh- 
bourhood was highly injected. Both lungs were the seat of consolidation 
which had broken down into cavities. The spleen was large, soft, and con- 
gested. The Malpighian tufts were not visible. The kidneys and liver 
were normal. The marrow of the right femur was mottled, red, and gray. 

The irregular or accidental symptoms arise from pressure set up by 
enlarged glands or organs upon adjacent parts. Thus the swollen glands 
in the neck may press upon the jugular veins, and by impeding the es- 
cape of blood from the interior of the skull, cause heaviness, drowsi- 
ness, oedema of the bead and neck, and epistaxis. They may also ham- 
per the movements of the lower jaw, press the larynx and trachea to 
one side, and cause dyspnoea by their interference with the air-passages. 
Sometimes they obstruct the channel of the gullet so that food passes with 
difficulty or swallowing becomes actually impossible. Enlargement of the 
bronchial glands may produce dyspnoea, spasmodic cough, and all the 
symptoms Avhich have been enumerated elsewhere as the consequence of 
pressure within the chest (see page 181). Growths of the mesenteric 
glands may set up ascites and jaundice by their pressure on the bile-ducts 
or portal vein, and oedema of the scrotum and lower limbs by their inter- 
ference with the return of blood through the inferior vena cava. 

Paralysis has been occasionally noticed. Thus Dr. Goodhart has reported 
the case of a little boy, aged six, who was admitted a patient under Dr. 
Pavy, in Guy's Hospital, for complete paraplegia, with incontinence of urine 
and deficiency of sensation below the umbilicus. After death a lympho- 
matous growth was found in the thorax, which had entered the spinal 
canal in the dorsal region by passing through the intervertebral foramina. 
Here it had lined the laminae of the vertebrae from the axis to the 
eighth cervical segment. In addition it had formed a mass which at one 
point completely filled the canal, compressed the cord, and had formed 
adhesions with the cord and the dur?, mater. Below this point the sub- 
arachnoid tissue was distended with fluid. 

In a case which was under my own care in the East London Children's 
Hospital — a boy ten years old, who suffered from an enormous mass of 
enlarged cervical glands on the right side of the neck, besides lesser en- 
largement of the mesenteric and inguinal glands — for some weeks be- 
fore the child's death ptosis was noticed of the right eyelid, and on exam- 
ination it was found that the pupil of that eye was somewhat dilated, 
and that there was paralysis of the internal rectus. At times, too, the boy 
complained of severe neuralgic pains in the right eyeball. After death, 
inspection of the body showed a mass the size of a walnut, which lay in 
the middle cerebral fossa, and was adherent to the dura mater covering the 
cavernous sinus. The mass had a prolongation wmich passed through 
the foramen lacerum medium and joined the general glandular mass in 
the neck. Its pressure upon the right third nerve had caused some 
atrophy of the nerve — for it was appreciably thinner than that on the left 
side — and had, no doubt, given rise to the paralytic symptoms which had 
been noticed during life. 

The duration of a case of lymphadenoma is very variable. When the 
illness begins as a local disease, the course is usually very slow at the first, 



LYMPHADENOMA— DIAGNOSIS— TREATMENT. 227 

and it may be years before the general glandular system becomes affected. 
When, however, the cachectic stage begins, the course is more acute. 
Still, the progress of the malady is always variable, and growth is more 
rapid at some times than at others. In the child the general disease 
rarely lasts longer than six or eight months. Death may result from asthe- 
nia or from some complication, as pneumonia, pleurisy, vomiting, or diar- 
rhoea. It may be preceded by convulsions. Sometimes the end is has- 
tened by the injurious effects of mechanical pressure upon the air-passages, 
the gullet, or the large veins of the abdomen. 

Diagnosis. — In the diagnosis of a case of lymphadenoma we have to 
search for evidence of general affection of the glandular system. So 
long as the disease remains limited to a few glands of the neck the nature 
of the swelling is not always easy to ascertain ; but even at this time it 
may be sometimes distinguished by the elasticity of the growth, for, ac- 
cording to Birch-Hirschfeld, even in the harder variety of lymphadenoma 
there is a certain elasticity as compared with the dense, boardlike hard- 
ness of the cheesy gland. Moreover, there is no inflammation set up 
round the mass, and caseous degeneration and softening are very rare. 
In a group of scrofulous glands some usually soften early and form an ab- 
scess. In such a case, too, the general signs of scrofula may be noticed. 

Sarcomatous glands present a greater likeness to lymphadenoma ; but 
when extension takes place in the former disease the tissues involved are 
not especially the lymphatic tissues ; indeed, the disease tends to spread 
rather to organs than to glands. 

In the cachectic stage lymphadenoma is usually easy of recognition. 
The irregular fever, the extreme pallor, the great drowsiness and unwill- 
ingness to speak, the general implication of lymphatic glands in all parts 
of the bod} 7 , the character of the blood, which shows diminution in the 
number of red corpuscles with no or only slight increase in the proportion 
of leucocytes. These symptoms are sufficiently characteristic. 

Prognosis. — Although some cases of recovery from this disease have 
been recorded, the illness is so generally fatal that little hope of a favour- 
able issue can be entertained. In the cachectic stage speedy death may 
be anticipated. In the earlier period a prolonged course may be hoped 
for, especially if the enlargement is slow ; but it is unwise to speak too 
favourably even of this prospect, for the disease may at any time suddenly 
assume an acuter character, and variations in the rapidity of its progress 
are not uncommon. Examination of the blood may be of some service in 
estimating the probabilities of a lengthened course. If the number of red 
corpuscles is greatly reduced, the child's prospects are very unfavourable. 

Treatment. — In every case the child should be put into as good sanitary 
conditions as possible, and every effort should be made to improve the 
general health. Cod-liver oil, iron, quinine, and tonics generally are use- 
ful in this respect, but none of these remedies have the power of delaying 
materially the progress of the disease after the affection of the lymphatic 
glands has become general. Arsenic, however, is highly spoken of for its 
value, even in this stage of the disease. The dose should be a large one ; 
and it must be remembered that most children have a special tolerance for 
this drug, being often able to take it in larger quantities than can be 
readily borne by the adult. For a child of eight years old ten drops of 
Fowler's solution may be given three times a day, freely diluted, directly 
after food, and every few days the dose can be increased by two drops. 
The effect of the medicine is to increase the softness and mobility of the 
glands. Soon pain begins to be complained of in the swellings, and this 



228 DISEASE IN" CHILDREN. 

is quickly followed by an arrest in their growth, or even an appreciable 
diminution in their size. Iron may be given with the arsenic if thought 
desirable, and the combination is preferred by some. Phosphorus has 
been also recommended as useful in promoting reduction in size of the 
glands ; but this drug appears to be decidedly inferior to arsenic. Iodide 
of potassium has been found quite useless as an absorbent in this disease. 

If the patient come under observation when the glandular swelling is 
limited to the neck, and the general system appears to be unaffected, we 
may begin the treatment with greater hopes of success. Early extirpation 
of the growths is often advocated, and the operation is said to have been 
followed in some cases by complete recovery. Even if this happy result 
be not attained, we may expect that in a suitable case the progress of the 
disease will be sensibly checked by the operation. "We can, however, only 
anticipate good results when the glandular enlargement is limited strictly 
to one group of glands, the spleen is unaffected, and the proportion of red 
corpuscles in the blood is not greatly reduced. Dr. Gowers recommends 
that in every case the actual proportion of red corpuscles be estimated by 
the hemacytometer, and states that if the proportion of coloured cells be 
less than sixty per cent, of the normal average, the idea of operating 
should be abandoned. On the other hand, a slight increase in the quan- 
tity of white corpuscles is not to be considered prejudicial to the success 
of the operation. After removal of the swollen glands the child should be 
sent to a bracing seaside air, and arsenic with quinine or iron should be 
given in full doses. 

According to some writers, friction of the growing glands with the 
hand alone or with some simple salve has been found useful, and com- 
pression and blistering have been also recommended. Injections into the 
glands of various substances, such as iodine, carbolic acid, etc., is not a 
safe method of treatment. In one case in which I injected tinct. iodi into 
a large lymphomatous swelling the operation was followed in a few days 
by a rapid and permanent increase in the size of the tumour. 



CHAPTER III. 

ANEMIA. 

Deterioration in the quality of the blood, combined often with deficiency 
in its quantity, is a common result in infancy and childhood of any con- 
dition which causes a temporary failure in the nutritive processes. In the 
child anaemia is commonly symptomatic of some discoverable ill ; for the 
obscurer form, called idiopathic or pernicious ansernia in the adult, is but 
rarely met with in early life. 

The reason of the exceptional frequency of impoverishment of the 
blood in childhood is not difficult of explanation. From the researches of 
Denis, Poggiale, "Wiskemann, and others, it appears that in infancy al- 
though the quantity of blood is greater than it is in maturer life, in propor- 
tion to the entire weight of the body, this blood is of lower specific gravity, 
and contains more white corpuscles, but less fibrine and soluble albumen, 
a smaller proportion of salts, and a considerably smaller quantity of haemo- 
globin, 1 With this comparatively dilute blood the growing child has to 
undertake a laiger work than is required from the adult. He has to sup- 
ply material for growth and development instead of merely maintaining 
the necessary nutrition of tissues and organs already matured. The heart 
and lungs are forced to greater efforts to answer the demands made upon 
them : the first to drive a sufficient quantity of blood along the relatively 
wider arterial channels ; the second to aerate the larger proportion of blood 
carried to them by the more capacious pulmonary artery. The lungs elimi- 
nate carbonic acid in far higher proportion than is the case in older per- 
sons. The amount of urea, too, excreted by the kidneys is relatively much 
greater than it is in the adult. The work required from the different se- 
cretory and excretory organs whose united labours go to build up the 
growing frame may be judged from the fact that within twelve months of 
its birth the body has increased to three times its original weight. As Dr. 
Jacoby has observed, the " organs are in constant exertion, or rather over- 
exertion, and all this at the expense of a blood which contains less solid 
constituents than the blood of the old. Thus the natural oligemia of the 
child is in constant danger of increasing from normal physiological pro- 
cesses. The slightest mishap reduces the equilibrium between the capital 
and the labour to be performed, and the chances for the diminution in the 
amount of blood in possession of the child are very frequent indeed." 

Although the blood of the child is thus relatively poor as compared 
with that of the adult, a constant inflow of nutrient material enables it to 
preserve a healthy standard and carry on its functions with success. The 



1 Haemoglobin is the chief constituent of the red corpuscles. In the newly born 
infant its amount is relatively larger than it is in the adult, reaching the high ration of 
22.2 per cent, of the whole solid" constituents (at adult age it is only 13.99 per cent.). 
This high percentage rapidly diminishes until it reaches the lowest point at the age of 
six months. It then slowly rises again. 



230 DISEASE IN CHILDREN. 

amount of food consumed by the growing child is far greater proportion- 
ately than that required by the fully developed man. According to Dr. 
Edward Smith, the infant as compared with the adult consumes three 
times as much carbon and six times as much nitrogen for every pound of 
his weight. If now, from any cause, either from deficiency in the supply 
of food, or derangement of the machinery by which food is elaborated and 
prepared for its purpose of nourishing and renewing the tissues, the inflow 
fails, the standard of the blood at once sinks below the average of health, 
and a state of anaemia or oligaemia (poorness of blood) is induced. 

The constituents of the blood which are of the greatest importance in 
nutrition are the albuminoid compounds of the plasma and the red blood 
corpuscles. The albuminoid compounds constitute the material out of 
which the tissues are nourished ; the haemoglobin of the red corpuscles 
carries the oxygen, without which the chemical changes necessary for nu- 
trition are impossible. In anaemia the blood is impoverished in its albu- 
minous constituents, especially in its haemoglobin. Therefore, as the 
amount of iron is in direct proportion to the amount of haemoglobin, a 
diminution in the latter means a deficiency in the former ; and as the chief 
office of the haemoglobin is that of conveying oxygen to the tissues, the 
blood in anaemia is no longer able efficiently to perform its respiratory and 
nutritive functions. 

Causation. — In early life any cause which interferes with the orderly 
renewal of the normal constituents of the blood leads to anaemia. In the 
infant — a being who is dependent for health upon a full daily supply of 
food — not only serious disease but even the most simple acute derange- 
ment will leave the blood in a state of temporary oligaemia. This is 
usually rapidly recovered from, for in the healthy child convalescence is 
short, and the nutritive functions quickly resume their course when the 
obstacle to their proper exercise has disappeared. By anaemia, however, 
is usually meant a more prolonged poorness of the blood — a condition in 
which the symptoms of general debility are allied with others indicating 
an imperfect performance of the bodily functions. 

The causes of such a condition maybe divided into two classes, accord- 
ing as to whether they interfere with the continued renovation of the blood 
or abnormally increase its consumption. 

In the first class are included all the various conditions which hinder 
the introduction and elaboration of nutritive material. Thus, actual defi- 
ciency of food, such as arises from extreme poverty or wilful neglect ; an 
unsuitable diet, the stomach being loaded with food which, from its nature 
or form, is beyond the child's power of digestion ; functional derangements 
of the gastro-intestinal canal, owing to which an otherwise suitable food 
is rendered temporarily inapproiniate — these causes may prevail at all 
periods of childhood, but are especially frequent during the period of 
infancy ; and the anaemia and wasting which are so common in hand-fed 
babies can usually be referred to the action of these agencies. To them 
must be added the influence of imperfect ventilation. Oxygen is as essen- 
tial to healthy tissue change as are the elements of food themselves, and in 
its absence the chemical changes necessary for the renewal and develop- 
ment of the tissues are impossible. Consequently infants confined to 
close, ill-ventilated rooms are pale and flabby, however carefully their 
dietary may be adjusted. 

The above causes are also powerful to impede nutrition and promote 
the impoverishment of the blood after the period of infancy has gone by. 
The influence of digestive derangements, combined or not with want of 



ANAEMIA — CAUSATION — MORBID ANATOMY. 231 

fresh air and exercise, is one of the commonest causes of anaemia in later 
childhood. The causes which induce impoverishment of the blood are no 
doubt often complex ; but of such as act alone imperfect digestion from 
catarrh of the stomach is perhaps to be blamed more often than any other 
injurious condition. These attacks tend to be repeated, and, as is else- 
where explained, recurring gastric catarrh may induce a degree of pallor 
and wasting which excites the greatest alarm in the minds of the parents, 
and often requires very careful treatment for its prevention and cure (see 
Gastric Catarrh). 

Again, the diathetic diseases — tuberculosis, scrofula, and syphilis — 
often induce a degree of anaemia, even before any local manifestations of 
the constitutional disposition are discoverable. In syphilis, also, the dis- 
ease, after apparent recovery, is apt to leave behind it a state of profound 
anaemia, which in many cases is to be attributed, not to the malady, but to 
the medication to which the patient has been subjected ; for a prolonged 
course of mercury is an unfailing cause of impoverishment of the blood. 
In rickets, the beginning of the disease is announced, and its progress 
accompanied, by a marked degree of anaemia, which indicates the unfit- 
ness of the blood in such a case to fulfil all the requirements of healthy 
nutrition. Of other special general diseases which may lead to diminution 
in the amount of haemoglobin and so set up anaemia may be mentioned 
rheumatism, scurvy, and the cachectic condition induced by malaria. 

Disease of special organs concerned in sanguification— the spleen, the 
lymphatic system, etc. — is, of course, followed by great alteration in the 
quality of the blood. In extensive amyloid degeneration of these organs, 
the marked pallor of the patient is one of the most striking symptoms of 
the disease ; and in lymphadenoma the patient is peculiarly pale and 
bloodless. 

The causes which increase the consumption of the blood are : Profuse 
haemorrhages,' as in melaena neonatorum, haemophilia and haemorrhagic 
purpura ; severe diarrhoea ; chronic purulent discharges, as in cases of 
chronic empyema with a fistulous opening in the chest-wall ; cirrhosis of 
lung with dilatation of bronchi ; albuminuria ; onanism ; etc. In this 
class, too, must be included rapid growth, which is a very frequent source 
of languor and anaemia. It must be remembered, however, that at the 
age when growth is apt to be most rapid the child is often exposed to 
other influences which may also tend to set up impoverishment of the 
blood, such as confinement to close rooms and want of exercise. 

Idiopathic anaemia (which is sometimes seen in young people) may re- 
sult from bad and insufficient food or other depressing cause acting upon 
the general system ; sometimes it is the consequence of mental shock, as in 
the case of a boy who was under the care of Sir William Gull, in Guy's 
Hospital. The lad began to suffer shortly after being attacked by a num- 
ber of sheep in a field. 

Morbid Anatomy. — In anaemia the blood may be merely deficient in 
amount (oligaemia), but it is usually found that there is also a deficiency in 
the haemoglobin (agiobulosis). It is not often that actual diminution in the 
number of the red corpuscles occurs in ordinary symptomatic anaemia un- 
less, indeed, the impoverishment result from severe haemorrhage ; but 
these bodies are said to be considerably reduced in size, and in certain 
forms of anaemia it is common to find many corpuscles with a diameter 
greatly below the average. The blood is paler than natural, for in con- 
sequence of the decrease in the haemoglobin it is deficient in iron. Jts 
specific gravity is also lower, and it coagulates slowly into a loose clot. 



232 DISEASE IN CHILDREN. 

As a result of the imperfect nutrition of the tissues which is the con- 
sequence of the deteriorated quality of the circulating fluid, a degree of 
fatty degeneration may be found in the heart, the liver, the kidneys, and 
even in the walls of the blood-vessels ; also in the voluntary muscles, and 
the glands of the stomach and intestines. 

In idiopathic anaemia fatty degeneration of organs is also commonly 
observed. There are, moreover, ecchymoses of serous membranes, the re- 
tina, etc. The blood is not only diminished in quantity, but the red 
blood corpuscles are also greatly reduced in number, being, according to 
M. Lepine, one-fourth, one-sixth, or even one-tenth of their normal pro- 
portions. The white corpuscles are not more numerous than natural, at 
least they are not increased to anything like the degree observed in leu- 
khaemia. In some cases of pernicious anaemia minute red corpuscles have 
been noticed measuring only one-fourth of their natural size, and wanting 
the characteristic bi-conate shape. These bodies, however, appear not to 
be present in every case. 

Symptoms. — Poorness of the blood implies an imperfect state of the 
general nutrition. This is especially the case in young subjects whose 
blood, as has been already explained, can only carry on its functions effi- 
ciently on the condition that it is continually reinforced by a regular inflow 
of properly elaborated nutritive material. Consequently, in addition to a 
general pallor, the muscles of such subjects are small and flabby, their 
strength is reduced, and their spirits may perhaps be depressed. Languor 
and indisposition to exercise are not, however, constant symptoms of 
anaemia in childhood. Boys suffer in this respect much less than girls, 
and when free from actual pain or discomfort such patients are often 
lively, and join wiih as much alacrity in boisterous games as if they were 
perfectly well. Indeed, this cheerfulness and activity may in some cases 
be an important aid to diagnosis (see Tuberculosis). 

The tint of the skin may be a clear, transparent whiteness. Often, 
however, it is dull and pasty ; or may have a faint greenish cast similar to 
the hue of chlorosis, and the lower eyelid may be livid and purplish. The 
mucous membranes are also pallid. Coldness of the extremities is a 
familiar feature of this condition. In anaemic little girls we are often told 
that the feet and legs are never warm, and the hands feel cold and clammy 
to the touch. Slight oedema is often met with. It may affect the lower 
eyelid, but less commonly than in the adult. Usually it is noticed in the 
feet and ankles, and if the anaemia be great, may involve also the hands 
and arms. In rare cases there may be moderate ascites. 

Breathlessness and palpitation on slight exertion sufficiently pronounced 
to cause distress are not common symptoms of anaemia in the child, but 
they are sometimes present. The appetite is often poor, discomfort may 
be complained of after food, and the bowels are usually confined. As this 
condition of the blood is in many cases a consequence of gastric derange- 
ment, all the symptoms which are elsewhere enumerated under the head- 
ing of gastric catarrh are often to be noticed. Flatulence, especially, is a 
common phenomenon, and faintness or actual syncope may occur from 
pressure upwards against the heart of a suddenly distended colon. The 
temperature is seldom elevated in an uncomplicated case of simple anaemia. 
Pyrexia may, however, be present as a consequence of the cause to which 
the impoverishment of the blood is owing, or to some accidental complica- 
tion, such as teething, catarrh, etc. 

Children, the subjects of anaemia, are usually very nervous and excit- 
able, and on examination of the chest we often find the heart acting violently, 



ANAEMIA— SYMPTOMS — DIAGNOSIS. 233 

can notice a strong pulsation in the neck, and with the hand placed upon 
the precordial region can feel a well-marked systolic thrill. As the violence 
of the cardiac action subsides the thrill ceases, and the carotid pulsations 
diminish or disappear. The sounds may then be heard to be ill-accen- 
tuated, or perhaps murmurish. Although anaemic cardiac murmurs are 
said to be uncommon in young subjects, it is not rare in cases of pro- 
nounced anemia to detect a murmur which ceases to be heard as the 
patient improves. The murmur may be at the apex of the heart and is — 
sometimes at least — accompanied by displacement of the apex-beat upwards 
and to the left, as if from dilatation of the left ventricle. Basic murmurs 
are, however, the more common phenomena. At the base of the heart the 
least pressure upon the pulmonary artery from enlarged bronchial glands 
will give rise to a loud systolic murmur in that vessel. In many cases we 
can hear a venous hum in the jugular vein in the neck, sometimes, also, in 
the left innominate vein, behind the upper part of the sternum. 

Bleeding from the nose and gums is not rare in anemic children ; and 
in hospital patients petechie are common in the skin as the result of flea- 
bites. From this cause the bodies of poor children are often speckled all 
over with little extravasations of blood. 

Pain across the forehead, or sometimes at the back of the head, is often 
complained of. In infants more serious symptoms may be met with as a 
consequence of anemia of the brain. The child lies with a pale shrunken 
face, eyelids only partially closed, and fontanelle depressed. His extrem- 
ities feel cold, and a thermometer in the rectum registers a temperature 
below the normal level. Soon the infant sinks into a state of semi-stupor, 
and unless aroused by energetic stimulation will probably die. Impover- 
ishment of blood and prostration so profound are apt to be complicated by 
thrombosis of the cerebral sinuses or collapse of the lung. 

The duration of a case of ordinary simple anemia varies according to 
the measures which may be taken to remove the cause or causes which are 
impeding the supply of nutritive material to the blood. If the cause can 
be removed, and the child be afterwards fed with judgment and placed 
under good sanitary conditions, recovery usually follows very quickly. 

In idiopathic anaemia all the preceding symptoms may be noted. In 
this form of the disease the anemia is more profound. The skin is of the 
colour of ivory and the mucous membranes seem perfectly bloodless. Optic 
neuritis may occur with hemorrhage into the retina. Epistaxis is common, 
and vomiting may be frequent and distressing. The child becomes exces- 
sively feeble, and has irregular attacks of pyrexia in which the temperature 
rises to 103° or 104°. Towards the end of the disease, however, elevation 
of temperature ceases to be noticed ; indeed, the bodily heat usually falls 
to a subnormal level. The blood has the characters already described. 

Diagnosis. — In every case of anemia it is important with regard to 
prognosis and treatment that we should exclude serious organic and 
diathetic disease. The diagnosis of the many conditions which induce 
impoverishment of the blood is treated of under their several headings. 
It may be only stated generally that if the cause lie elsewhere than in some 
obvious derangement of the digestion, we should institute very searching 
inquiry into the family and special history of the patient, particularly with 
regard to diathetic tendencies, and should make careful examination of 
the various organs. 

Idiopathic anemia may be distinguished by the profound deterioration 
of the blood without increase in the white corpuscles ; the absence of dis- 
coverable cause for the pallor and weakness ; and the attacks of irregular 



234 DISEASE IN CHILDREN. 

pyrexia. Leucocythemia is characterised by increase in the proportion of 
white corpuscles, and by enlargement of the spleen or lymphatic glands. 

Prognosis. — In anaemia the prognosis depends very much upon the 
primary disease, if any such can be discovered. If the poorness of blood 
be the sequel of some previous acute illness, or other cause which has 
ceased to prevail, the patient usually responds well to treatment and 
quickly recovers under ordinary restorative measures. In cases of idio- 
pathic anaemia, when the prostration is great, the pallor extreme, and the 
temperature high, the child's prospects are very unfavourable. 

Treatment. — Anaemia must be treated according to the cause which 
has produced it. Impaired nutrition and a pallid face form in themselves 
no necessary indication for the employment of chalybeate remedies. The 
commonest cause of anaemia in the child, as has already been stated, is 
gastro-intestinal derangement. In such a case iron has no power to im- 
prove the condition of the blood until the hindrance to digestion has been 
removed. In anaemic infants the dietary must be reconstructed upon the 
principles recommended elsewhere (see Infantile Atrophy). In older 
children if, as often happens, the patient be suffering from repeated attacks 
of gastric catarrh more or less severe, the digestive disturbance must 
receive careful treatment, and measures must be adopted to lessen the 
child's susceptibility to changes of temperature and to protect his sensi- 
tive body from the cold (see Gastric Catarrh). In all cases plenty of fresh 
air should be prescribed. The parents should be warned of the necessity 
of thorough ventilation of nurseries and sleeping-rooms, and the child must 
be sent out as much as possible into the open air. It is important, how- 
ever, not to force the patient to take exercise when his feeble powers will 
not admit of his deriving benefit from muscular activity. If his weakness 
be great, the child should go out only in a carriage ; and when in-doors 
care should be taken that his wearied muscles are allowed a sufficiency of 
needful rest. As he mends, however, he should be urged more and more 
to exert himself, and in severe cases a desire for exercise is a valuable 
sign of improvement. 

The child must take plenty of nitrogenous food, and if, as sometimes 
happens, the appetite is poor, with a special dislike to meat, his fancies 
must be consulted in every way possible. Often a child will eat a small 
bird, as a lark or a snipe, when he turns with disgust from beef and 
mutton. Pounded underdone meat spread upon bread and butter will 
often be taken, or the meat may be diffused through a meat jelly. Eggs, 
milk, and fish are all of service, and a moderate quantity of farinaceous 
food may be allowed ; but the child must be prevented from taking starchy 
matters to the exclusion of more nutritious articles of diet. When the 
appetite is poor, it may be often improved by taking three times a day a 
drop or two drops of the dilute hydrocyanic acid (P. B.) with five grains 
of bicarbonate of soda in infusion of orange peel. The draught can be 
sweetened with spirits of chloroform, and should be taken an hour before 
meals. 

Iron is only to be resorted to as an addition to the more general meas- 
ures for restoring nutrition and improving digestive power, and it must 
not be given until the disorder of the gastric functions has been attended 
to. Iron acts far more energetically when it is combined with aperients. 
Often, indeed, until the bowels have been well relieved by appropriate 
purgation the remedy seems to be perfectly inert. Not seldom, after giv- 
ing an iron mixture perseveringiy for a length of time without any sign of 
improvement, I have noticed an immediate alteration for the better when 



ANJSMIA— PROGNOSIS— TREATMENT. 235 

the chalybeate has been exchanged for a morning and evening dose of the 
compound senna mixture of the British Pharmacopoeia. The form in which 
the iron is given is of little importance. The dose should always be as 
large a one as the child can bear without discomfort ; and if the digestion 
be in good order, the acid preparations are to be preferred as a rule to the 
alkaline salts. Still, if there be any remains of catarrh of the stomach, the 
ammonio-citrate should be given with an alkali. Most children bear the 
sulphate of iron well. For a child of six years old, five grains of the dried 
salt may be given in a teaspoonful of glycerine three times a day directly 
after food. This dose may seem rather a large one, but it is rare to find 
any signs of irritation produced by the medicine, and the tonic effect upon 
the s} r stem is usually rapid and decided. The perchloride is also a good 
form for administration of the remedy. Twenty to thirty drops, well di- 
luted with water and sweetened with glycerine, may be taken after each 
meal. These preparations are far more useful than the various iron syrups 
which are commonly preferred. I have seen many a case of anaemia aris- 
ing from gastric catarrh prolonged by the use of these syrups, which 
promote acidity and flatulence and encourage the excessive secretion of 
mucus. 

In some children almost all forms of iron seem to act as direct irritants 
to the stomach, inducing indigestion and peevishness of temper and caus- 
ing wakefulness at night. In these cases the dialysed iron is the best 
form in which the remedy can be administered. Pure chalybeate waters 
are also of service if the child can be induced to take them. Their value 
is, no doubt, enhanced by the fresh country air and exercise by which the 
change to a chalybeate spring is usually accompanied.' 

Under the use of iron the red corpuscles increase in size and the pro- 
portion of haemoglobin is therefore largely augmented. The improvement 
is announced by a healthier tint in the complexion, an improvement in the 
appetite, and, if the child had been previously listless and dull, by greater 
freedom and sprightliness in his movements. 

Arsenic is another remedy of great value in improving the condition of 
the blood. Children bear arsenic well. The drug, unless given in very 
large quantities, is rarely a cause of gastric irritation. In fact, as is well 
known, arsenic in small doses is a valuable sedative to the digestive organs 
and often arrests vomiting. As a tonic the remedy should be given to a 
child of six years old in the dose of three or four minims of Fowler's solu- 
tion directly after food. When the digestion is greatly impaired by re- 
peated attacks of gastric catarrh the effect of this medication is often very 
striking. The arsenic may be usefully combined with a drop or two of the 
tincture of nux vomica. Another remedy from which good results have 
been obtained is phosphorus. This powerful drug may be safely given to 
a child of six years old in doses of t |--q to T -J-y of a grain. I have, however, 
no personal experience of its value. 

Cod-liver oil is of service as an additional food, and in combination 
with iron wine is a favourite remedy in all forms of anaemia in young sub- 
jects. The alcohol of the vinum ferri is no doubt a valuable therapeutic 
agent. Alcoholic stimulants taken with food help to promote digestion, 
and in many pallid, weakly children have great virtue in aiding the return 
to health. Sound claret, or the St. Raphael tannin wine, diluted with an 
equal proportion of water, is usually taken readily by the child, and is a 
sensible help to other treatment. 

Cold-water packing is said to be useful in improving the condition of 
the blood. Drs. M. P. Jacoby and V. White have reported a series of 



236 DISEASE IN CHILDREN. 

cases in which anaemia was treated by the regular application of the cold 
pack followed by massage. The patient was enveloped in a cold wet sheet, 
this was covered by a drier sheet, and over all six blankets were laid and 
carefully tucked in. After the lapse of an hour the coverings were re- 
moved and the skin and muscles were vigorously shampooed. This plan 
of treatment was combined with rest and careful feeding, and was attended 
by very good results. It might be employed with advantage in the case or' 
weakly, pallid children in whom anorexia is a marked feature, for one of 
its most pronounced effects was found to be an immediate improvement in 
the appetite. The induction of sleepiness by the pack and massage is 
usually an indication that the patient is benefiting by the treatment. 



CHAPTER IY. 

ENLARGEMENT OF THE SPLEEN. 

Enlargement of the spleen is common in early life, and is found in the 
course of a variety of diseases. The symptom is alluded to incidentally in 
the descriptions of the various forms of illness in which the phenomenon 
occurs ; but the subject is of sufficient importance in a clinical point of 
view to deserve a special chapter for its consideration. 

A splenic tumour may be of acute or chronic growth. Acute enlarge- 
ment is seen in typhoid fever and ague, sometimes in acute tuberculosis, and, 
it is said, in cerebro-spinal fever ; also the enlarged spleen found in cases of 
leucocythemia may be included in this class, for in early life leukhsemia 
often runs an acute course. Eapid increase in size of the organ is also oc- 
casionally met with as a result of splenic embolism in the course of ulcera- 
tive endocarditis. 

Chronic enlargement of the spleen may be the consequence, and some- 
times the only manifestation, of the cachectic condition induced by mala- 
rious poison. It occurs in some cases of amyloid degeneration, although 
a spleen so affected is not always increased in size. It is a common symp- 
tom of lymphadenoma, is not unfrequently a consequence of atrophic 
cirrhosis of the liver, and may be met with in cases of old-standing dis- 
ease of the heart. Lastly, it may be due to a simple hyperplasia. Hyper- 
trophy of the spleen may occur in rickets and syphilis, especially the latter ; 
but is also found in cases where syphilis may be positively excluded, and 
in cases, too, where there is no reason to suspect any malarious origin of 
the swelling. 

In the child a spleen is not necessarily diseased because its lower edge 
is within reach of the finger. The healthy organ is sometimes pushed down, 
so as to be felt. This displacement may occur in cases of copious effusion 
into the left pleura, and is common in rickets where there is much retrac- 
tion of the ribs. 

In determining the existence of enlargement of the spleen it is not suf- 
ficient merely to ascertain the position of the lower edge ; for considerable 
swelling of the organ may be present although its inferior border does not 
project below the margin of the ribs. In the child the spleen often extends 
backwards and upwards as well as downwards, and may reach posteriorly to 
the spinal column. By percussion in such cases we can often detect dulness 
in the axilla reaching upwards as far as the fourth or fifth rib, and in the 
back extending as far upwards as the inferior angle of the scapula. In all 
cases where a splenic tumour is suspected the size of the organ should be 
estimated by percussion as well as palpation. When the lower part of the 
organ projects below the ribs into the abdomen it is easily felt by laying the 
hand flat upon the belly and pressing gently with the finger tips. That 
the swelling thus discovered is due to increase in size of the spleen is indi- 
cated by the superficial position of the tumour, by the comparative thinness 



238 DISEASE IN CHILDREN. 

of its inner border, and by the notch which can often be distinctly perceived 
by the finger. 

An enlarged spleen is usually firm and resisting to the touch, especially 
if the enlargement is a. chronic process. In typhoid fever, however, the 
substance of the swollen organ is unusually soft, and on this account can 
sometimes be only felt by a practised finger. In acute forms of swelling 
the increase in size is accompanied by some tenderness on pressure. In 
chronic enlargements there may be also tenderness, but this is commonly 
due in such cases to the presence of local peritonitis. 

In the present chapter it will be unnecessary to refer again to all the 
forms of sj^lenic tumour met with in the child. It will be sufficient to con- 
sider the chronic enlargement which occurs as a consequence of a simple 
hyperplasia of the organ. 

Simple Hyperplasia of the spleen is a not uncommon condition in in- 
fancy and early childhood. Often the patient may bear traces of inherited 
syphilis or show some symptoms of rickets ; but this is not always the case, 
and sometimes no sign of diathetic disease or constitutional weakness is 
anywhere to be detected. When the enlargement is thus present in a child 
of apparently healthy constitution its etiology is difficult to establish. In 
some of the cases which have come under my notice the enlargement has 
been preceded by gastro-intestinal derangement. In others the child has 
been subject to frequent attacks of pulmonary catarrh. Sometimes the 
splenic tumour was first discovered shortly after an attack of measles ; but 
it is difficult to admit a connection between these derangements and the 
splenic hyperplasia. 

Morbid Anatomy. — When enlarged from simple hypertrophy the spleen 
retains its normal shape. It is firm and smooth ; its capsule is thickeued ; 
and a section shows a pale red or reddish purple surface, with the Malpighian 
bodies more or less distinctly visible. 

Symptoms. — The existence of enlargement of the spleen is at once in- 
dicated by the complexion of the child. The whole body — both skin and 
mucous membranes — is pale and bloodless ; but the tint of the face is 
characteristic. It has something of the colour of ivory or wax, with the 
addition of a faint olive cast which is not found in either of these substances. 
Often we notice a curious transparency, especially about the mouth and 
eyelids. The belly is large and the spleen can be readily felt as a smooth, 
firm mass. If the increase in size is great, the tumour projects diagonally 
across the abdomen, and presents on its inner surface the abrupt edge 
broken towards the middle by the notch. Usually the organ projects up- 
wards and to the back as well as downwards, and its limits in these direc- 
tions can be estimated by percussion. Sometimes it is freely movable by 
the hands, and it always descends when a deep breath is taken, rising again 
in expiration. 

Although pale and bloodless the child has often a considerable amount 
of flesh, and is greatly wasted only in exceptional cases. He is, however, 
weak and languid. The bowels are often irritable, and in children of three 
or four years old the appetite is capricious and perhaps perverted, so that 
the patient shows a curious tendency to eat cinders, chalk, slate-pencil, 
and other gritty or even disgusting substances. (Edema of the lower 
limbs and eyelids is sometimes noticed, and petechia and bruise-like 
patches may be present in the skin. There is also a marked tendency to 
epistaxis. 

On examination of the blood the red corpuscles form rouleaux in the 
usual manner ; but tested by the hemacytometer their number is found 



ENLARGEMENT OF THE SPLEEN — SYMPTOMS. 239 

to be reduced considerably below the normal average, and the white cells 
are often appreciably increased, although seldom to the degree observed 
in cases of leucocythemia. Sometimes both red and white corpuscles are 
irregular in shape. 

A little boy, aged one year and seven months, was said to have been 
born strong and healthy. He was the youngest of four, his elders being 
all strong and well. He did not snuffle after birth, nor were any spots 
noticed at that time on the buttocks. Until the age of ten months the 
child excited no anxiety, but he then began to get pale and to lose flesh. 
He had been lately very restless at night. 

On examination the infant was seen to be very amemic over the whole 
body, and his complexion was of a dull yellowish-white, especially on the 
cheeks. He was thin although not emaciated, and his expression showed 
no sign of distress. The child was the subject of slight rickets, he had 
only two teeth, his chest was a little flattened laterally, and there was in- 
significant enlargement of the epiphyses of the long bones. His legs were 
small, and he had never been able to walk. The fontanelle was about half 
an inch in diameter. The frontal bone was rather prominent on each side 
of the middle line, and there was some inconsiderable thickening of the 
parietal bones. Cranio-tabes was well marked. 

The belly was very full and prominent, especially on the left side. As 
the child lay on his back, the lower border of the spleen was found to reach 
to the left crest of the ilium, and the inner margin passed obliquely down- 
wards from beneath the ribs to within two finger s'-breadth of the right 
anterior superior spine of the ilium. The notch was felt just above the 
umbilicus. The organ was freely movable, descending appreciably in in- 
spiration, and it could be pushed upwards until its lower border was on a 
level with the naveL Its substance was firm and hard, and its surface 
smooth. The upper border, estimated by percussion, rose to within two 
fingers'-breadth of the inferior angle of the left scapula. The edge of 
the liver was one inch below the costal margin. A small nodule could be 
felt on each side behind the ramus of the lower jaw ; otherwise there was 
no enlargement of the lymphatic glands. A little blue mark, like a bruise, 
was noticed on the forehead, and there was another on the back, but there 
were no petechia present on the skin. There was no oedema of the legs. 
The child's appetite was good, and he was not suffering from digestive dis- 
turbance. An examination of the blood showed no excess of white cor- 
puscles. 

Children in whom great enlargement of the spleen exists are very sub- 
ject to gastro-intestinal troubles, and in consequence of their weakness are 
frequent sufferers from every form of catarrhal derangement. In fact, 
they usually die from a severe diarrhoea or an attack of bronchitis or ca- 
tarrhal pneumonia. If they escape these accidents recovery is not impossi- 
ble. We sometimes find the spleen gradually diminish in size and eventu- 
ally return to its normal dimensions. 

A little boy, aged twelve months, with no teeth, was brought to me. as 
he was said to be weakly. The child had been reared by hand, and was 
subject to attacks of sickness. A short time previously, during a visit to 
the seaside, he had been jaundiced. There was some slight enlargement 
of the ends of the bones and his fontanelle was large. The child could 
not stand, but liked to be danced about and played with. His complexion 
was excessively pale, with a faint olive cast. The abdomen was full, and 
the spleen, which was large and hard, reached to the level of the navel. 
The child was put upon a nutritious diet, and was ordered cod-liver" oil 



240 DISEASE IN CHILDEEN. 

and plenty of fresh air. In five months' time he had cut ten teeth, and 
although still pale, had a better complexion. Seven months afterwards 
(twelve from his first visit) he had sixteen teeth and could run about well. 
His spleen was now greatly reduced in size, being just perceptible below 
the ribs. His complexion was good and he seemed perfectly well. 

In this case no special medication w T as attempted with the object of 
reducing the size of the spleen. The general weakly state was improved 
by fresh air and a suitable dietary, and cod-liver oil Avas given on account 
of the signs of incipient rickets. Moreover, further intestinal catarrhs 
were prevented by a carefully applied abdominal bandage. The hope that 
under these altered conditions the size of the spleen would diminish as the 
general health improved was perfectly justified by the event. 

Diagnosis. — There is little difficulty about the diagnosis of these cases. 
The complexion of the child is very characteristic. Indeed, in a young- 
child extreme anaemia should always direct attention to the spleen. When 
a hard lump is discovered in the left side of the abdomen, it is easy 
to ascertain if the swelling is due to sj)lenic enlargement. The superficial 
position of the tumour ; its passing upwards beneath the ribs ; its less 
rounded inner edge, with a perceptible notch ; the free mobility of the 
mass, which can be pressed upwards by the fingers, and may be seen to 
move in correspondence with respiration, descending when a deep breath 
is drawn, and rising again with the diaphragm as the lungs contract — all 
these signs leave little doubt of the nature of the enlargement. That the 
tumefaction is a simple hypertrophy, and is not due to lymphadenoma or 
leucocythemia, is inferred from the absence of lymphatic enlargements in 
the former case, and in the latter from the small increase in number of the 
white corpuscles of the blood. 

Prognosis. — The prospects of the child in simple hyperplasia of the 
spleen depend in a great measure upon the care bestowed upon him, and 
the watchfulness with which he is guarded from intercurrent ailments. 
The prognosis is therefore much more favourable in the case of children of 
well-to-do parents than in those belonging to the class by which our hos- 
pitals are supplied. If the patient show marked signs of rickets or syphi- 
lis, a cure can hardly be anticipated ; but if the signs of rickets are only 
moderately developed, or the syphilitic origin of the enlargement is merely 
a matter of susjricion, the child, under favourable conditions, has a fair 
chance of recovery. Any considerable excess of white corpuscles in the 
blood must greatly diminish our hopes of a successful termination to the 
case. 

Treatment. — In the treatment of cases of simple hypertrophy of the 
spleen we must not allow our attention to be directed too exclusively to 
the swollen organ, to the neglect of the general health. Much injury is 
often done in these cases by long courses of mercury or iodide of potas- 
sium, and the energetic application of mercurial ointments to the left 
hypochondrium. 

Our first care should be to attend to any gastro-intestinal derangement 
which may be interfering with the patient's nutrition. Vomiting must be 
stopped, looseness of the bowels must be arrested, and the diet must be 
arranged so as to supply the most ample nourishment with the least tax 
upon the digestive powers. Most of the patients are weakly children 
under two years of age. They must therefore be dieted upon the prin- 
ciples recommended in the chapter on Infantile Atrophy. Milk, yolk of 
egg, Mellin's food, Chapman's baked flour, broths, thin bread and butter, 
and, if the child is eighteen months old, raw or underdone mutton, pounded 



ENLARGEMENT OF THE SPLEEN — DIAGNOSIS — TREATMENT. 241 

in a mortar and strained through a fine sieve, should be given. Watch- 
fulness must be exercised that the size and frequency of the meals are 
duly proportioned to the digestive capabilities of the patient ; and in the 
case of milk, in particular, it is important, by careful inspection of the 
stools, to satisfy ourselves that curd is not passing away in large quantities 
by the bowels, If this be the case, milk should not be given pure as a 
drink, but be always mixed with barley-water or other thickening material, 
so as to aid its digestion by insuring a fine division of the curd. Three 
or four grains of pepsine, given just before the three principal meals, will 
be of great assistance in these cases. 

Having attended to the diet, attention should next be directed to the 
clothing of the child. These patients, especially if they show any signs of 
rickets, are very sensitive to changes of temperature, and it is of extreme 
importance that they should be thoroughly protected from chills. The 
belly should be covered with a broad flannel belt. This must be applied 
carefully, so as to cover the whole of the abdomen, from the hips to the 
waist, and should fit closely to the skin. In cold or changeable weather 
the child's legs and thighs should be protected by long woollen stockings, 
and all his underclothing should be of flannel or wool. So protected, the 
patient must be taken out of doors as much as possible, and in suitable 
weather should pass the greater part of the day out of the house. Before 
he leaves home, his feet should be examined to see that they are perfectly 
warm ; and in cold weather it is best to pack the child in a perambulator, 
so that his back and sides may be properly supported. His feet can then 
rest upon a hot-water bottle. If the patient be sent to a good seaside air, 
the effect of these measures is often very marked. 

For medicine, unless there are positive signs of syphilis, mercurials 
and other lowering drugs should not be employed. The best treatment 
consists in the use of iron in full doses and cod-liver oil ; but this treat- 
ment must not be begun until the bowels have been put into a healthy 
state by appropriate remedies. For a child of eighteen months of age 
two or three grains of the exsiccated sulphate of iron may be given in gly- 
cerine ; or ten drops of the tincture of perchloride of iron may be adminis- 
tered, freely diluted with water and sweetened with glycerine, three times 
a day after meals. Quinine is also of service, and may be given in con- 
junction with the iron. The value of alcohol must not be forgotten. A 
teaspoonful of the St. Eaphael tannin wine, given two or three times a 
day, diluted with an equal quantity of water, is an important addition to 
the treatment. 

I have employed frictions with mercurial salves to the splenic region, 
and seen them used by others, but have never noticed any special benefit 
from this proceeding. As a rule, it has seemed to me that the anrernia 
has been intensified by this means, and that the size of the spleen has in- 
creased rather than diminished under the use of the drug. Unless the 
employment of the remedy is distinctly indicated by clear evidence of the 
presence of syphilis in the child, this method of treatment seems likely to 
be attended with a bad rather than a good result. 
16 



CHAPTER Y. 

HEMOPHILIA. 

Hemophilia is a congenital tendency to bleeding which manifests itself 
shortly after birth and lasts the life of the patient. The haemorrhage oc- 
curs either spontaneously or upon slight provocation, and can only be 
arrested with great difficulty. The subjects of the disease also exhibit a 
curious tendency to obstinate swellings of the joints, which are often 
spoken of as "rheumatism." A temporary disposition to haemorrhages, 
such as is sometimes left after certain diseases, does not constitute haemo- 
philia. The true disease dates from birth, or appears shortly after it ; is 
always seen in childhood, and persists, as a rule, to the very end of life. 

GausoMon. — Haemophilia, if not invariably hereditary, shows a singular 
tendency to hereditary transmission. The proclivity manifests itself more 
frequently in the male than in the female offspring ; but the females, if 
themselves exempt from this peculiarity, are still capable of transmitting 
the disease to their children. It is, indeed, a curious fact that the trans- 
mission of the tendency to the child is seen more commonly in cases where 
the patient, whether male or female, although sprung from a family of 
bleeders, is individually free from the haemorrhagic disposition. It is rare 
to find a father transmit the disease to his child if he is himself a sufferer. 
In the majority of cases the unfortunate inheritance is derived from the 
mother, who has probably escaped. 

In a family subject to this tendency all the male children may prove 
bleeders. Sometimes, however, one or more escape. Dr. "Wickham Legg 
is of opinion that when transmission is only partial the first-born are more 
exempt than the others. The disease is found in all countries and all con- 
ditions of life. The Hebrew race is said to be peculiarly liable to it. 

Morbid Anatomy. — In cases of death from haemophilia little is found to 
explain the nature of the disease. The body is usually blanched from loss 
of blood, but the organs, especially the heart and large vessels, present no 
appearance of disease. No change is discovered in the blood, and the 
vessels seldom present any alterations recognisable by the microscope. In 
some cases, indeed, a partial fatty degeneration of the lining membrane of 
the arteries has been observed ; but this is probably the consequence of 
the anaemia. Petechiae in the skin, and bruise-like patches from subcuta- 
neous extravasation, may be found ; and sometimes large collections of 
blood have been met with. Sir W. Jenner has reported the case of a boy, 
aged thirteen years, in whom an enormous extravasation of blood was dis- 
covered beneath the fascia of the right thigh. The swelling of the joints 
appears to be due to extravasation of blood into the articulations. In a 
case reported by M. Poncet, on opening the knee-joint, which had been 
obstinately swollen and painful during life, all the tissues of the articula- 
tion were found to be stained with blood. At the circumference the tis- 
sues were chocolate-coloured ; the articular surfaces were red and impreg- 



HAEMOPHILIA — MORBID ANATOMY — SYMPTOMS. 243 

nated with blood ; and the cartilages were the seat of advanced lesions 
such as have been described by Charcot as characteristic of chronic rheu- 
matism. Microscopic examination revealed in the substance of the tissues 
yellow granules, irregular or rounded, and of variable size, pigment gran- 
ules, and fat granules. Other joints in the same subject showed similar 
lesions. 

Symptoms. — There is nothing in the look of the child at birth to indi- 
cate any peculiarity of constitution. Nor in after years, unless the indi- 
vidual be actually suffering from loss of blood or disease of the joints, is 
there anything in his appearance to distinguish him from another without 
the same tendency to bleed. The child may be fair or dark, tall or short, 
of robust frame or of slender build. As a rule, he looks healthy, and his 
intellectual capacity is above the average. 

It is rarely before the end of the first twelve months of life that any 
sign is noticed of the hemorrhagic disposition. Bleeding seldom occurs at 
the time of separation of the umbilical cord, or during the operation of 
vaccination ; and it is not until the infant is able to crawl or walk, and 
thus becomes exposed to injuries from falls or other violence, that his con- 
stitutional peculiarity can be recognised. Sometimes, however, evidence 
of the disease is postponed until later. Bleeding may not be noticed until 
the second crop of teeth begins to make its appearance at about the sixth 
year. It has even been known to come on for the first time at a later 
period ; but is rarely delayed till after puberty. 

The propensity to bleed varies greatly in its intensity in different sub- 
jects. In the lowest degree it may show itself merely in the shape of 
ecchymoses in the skin. In a higher grade the patient may complain of 
spontaneous haemorrhage from the mucous membranes. In its most pro- 
nounced form a tendency to every kind of bleeding is observed. The 
mucous membranes may pour out blood without obvious cause ; slight in- 
juries may give rise to copious extravasation into the tissues ; petechias 
may appear in the skin ; and obstinate and painful swellings may attack 
the joints. 

The haemorrhage usually occurs at a time when the patient appears to 
be in unusually good health, for it is at these times that there is a plethora 
of the smaller vessels. The'bleeding may be preceded by signs of excite- 
ment or irritability of temper, and it is said that there is sharpening of 
the senses of hearing and of sight. Epileptiform convulsions have been 
noticed in one case by Boier. 

If the bleeding be spontaneous, it occurs in the child usually from the 
nose ; but may be also noticed from the inside of the cheeks and lips, and 
from the gums, especially during dentition. In less common cases blood 
is also poured out from the mucous membrane of the stomach and bowels, 
and may be vomited up or discharged by stool. As a rule, the younger 
the child the more likely is the haemorrhage to come from the nose or 
mouth. It is only towards puberty that haematemesis or nielaena becomes 
common. Renal haemorrhage is rare. Once started, the loss of blood may be 
continuous and copious, so as to be arrested with the greatest difficulty ; or 
may cease for a time and then return. Sometimes haemorrhage from one 
source is quickly followed by a similar effusion from another, until the pa- 
tient dies worn out by the constant discharge. When bleeding from one 
source alone ends in death, the hemorrhage occurs usually from the nose. 

In addition to the spontaneous haemorrhages, slight wounds or blows 
may produce a copious effusion. Little cuts or scratches bleed obstinately ; 
slight blows upon the body may be a cause of serious extravasation ; and 



244 DISEASE IN CHILDREN. 

in certain subjects even the rising of a blister may fill the bleb with blood 
instead of serum. In such patients the extraction of a tooth, the applica- 
tion of a leech, or the prick of a pin may induce bleeding which for a long- 
time resists the most powerful styptics, and may even destroy the life of 
the patient in spite of the most energetic measures for its suppression. 

The tendency to bleed, even in the case of the same child, is subject to 
curious variation. A slight injury which at one time gives rise to exces- 
sive hemorrhage, at another is followed by no ill consequences ; and a 
child in whom repeated hemorrhages from the nose or mouth are a source 
of anxiety may bear the removal of a tooth without unusual bleeding fol- 
lowing the operation. Thus Dr. Wickham Legg has reported the case of 
a boy, aged eight years, who was subject to frequent hemorrhages from 
the nose and gums. This child could bear the extraction of a tooth or a 
cut on the finger without much loss of blood. 

In all cases the source of the bleeding is capillary. The hemorrhage 
occurs as a constant oozing, which may last for hours, days, or weeks ; and 
it is astonishing to note the enormous quantity of blood which may be 
thus poured out by the most trifling wound. In the case of traumatic 
bleeding the hemorrhage usually begins some hours after the infliction of 
*the injury. It often does not cease until the patient becomes faint, and 
even then is liable to renewal when consciousness returns. By this means 
the child may be reduced to a state of profound anemia, and only slowly 
regains his colour and strength. 

The petechie and subcutaneous hemorrhages which occur in hemo- 
philia are very similar to those noticed in cases of purpura. They are com- 
mon on the buttocks and limbs of infant bleeders, but the face usually es- 
capes. Trifling blows may produce copious effusions. In some cases the 
blood infiltrates extensively through the areolar tissue of a limb, and death 
may even ensue from this inward bleeding. In other cases circumscribed 
collections of blood may be noticed, forming tumours of various sizes. 

One of the most curious features of the disease in its higher grade is 
the joint affection to which these patients are so subject. The articula- 
tions attacked are usually the larger ones, and in the majority of cases it 
is the knee which suffers ; but the ankles and hips, the shoulders and el- 
bows are liable to be affected. The joint becomes swollen and tender, and 
the swelling usually increases until the ends of the bones can no longer be 
felt. It is accompanied by pain which is increased by movement, and 
there is a rise of temperature. Sometimes fluctuation may be detected. 
The swelling is said to be due, in some cases, to a simple effusion into the 
joint ; but it is more commonly the consequence of articular hemorrhage. 
It may occur either spontaneously or as the result of a trifling injury. The 
symptom persists for a variable time, and it may be months before the 
joint returns to its ordinary dimensions. Several joints may be attacked in 
succession, or the joint affection may alternate with some form of visible 
hemorrhage. Blood tumours sometimes rise on the sides of a diseased 
joint. Thus M. Poncet has recorded the case of a boy, aged sixteen, whose 
right knee had been painful, stiff, and swollen for two years. Some time 
previously a small swelling had formed on the inner side of the knee. 
This had turned black, and then had burst, giving rise to obstinate hemor- 
rhage. The boy was very subject to profuse bleedings from the nose, 
and eventually died in consequence of repeated hemorrhage from wounds 
made by the application of the actual cautery to the diseased joint. 

In addition to the articular affection, pains may be complained of in 
the limbs about the joints, although unaccompanied by swelling. These 



HAEMOPHILIA— SYMPTOMS— DIAGNOSIS. 245 

may be so severe as to interfere with exercise. The subjects of haemo- 
philia also suffer much from cold, and the haemorrhage may be determined 
by exposure to weather. 

It might, perhaps, be expected that the existence of the constitutional 
tendency would influence unfavourably the course of the exanthemata and 
other intercurrent diseases to which childhood is liable ; but this does not 
appear to be the case. Measles, scarlet fever, and whooping-cough are 
said to run their normal course in such subjects without manifesting ex- 
ceptionally unfavourable symptoms ; and although the patients are prone 
to chest affections, such as pleurisy and pneumonia, these diseases are not 
attended with special dangers. There is no peculiar liability to phthisis ; 
but sloughing and gangrene are said to be not uncommon accidents in the 
course of wounds and traumatic injuries generally. 

Diagnosis. — In pronounced cases the detection of the hemorrhagic 
tendency is a matter of little difficulty. The history of repeated bleedings, 
the habitual appearance of bruises upon slight injury, and the affection of 
the joints, furnish sufficient evidence of the existence of this constitutional 
peculiarity. In cases where the tendency is present in a less degree the 
diagnosis is not so easy. Repeated epistaxis is often seen in children 
whose health in other respects is perfectly satisfactory ; and the occurrence 
of spontaneous haemorrhage from this source is therefore of no value in 
establishing the existence of hemophilia. Again, profuse and even fatal 
bleeding from the stomach and bowels may be met with in new-born in- 
fants. The cause of haemorrhage in the newly-born is often obscure ; and 
in the absence of any evident reason for its occurrence some observers 
have attributed it to a special hemorrhagic tendency existing in the in- 
fant. This may be so ; but the cases differ from haemophilia in the fact 
that where life is preserved no special proneness to bleeding is manifested 
in after years (see page 655). So, also, in hemorrhagic purpura profuse 
bleeding may occur from all the mucous surfaces and into the tissues ; but 
the disposition to bleed is here, also, a temporary infirmity which passes 
off and is completely recovered from. 

In all cases of true hemophilia careful inquiry will discover the exis- 
tence of a hereditary tendency, especially on the side of the mother, and 
also in most cases a disposition on the part of the child himself to bleed 
profusely upon slight provocation. 

The nature of the joint affection can only be discovered by establishing 
the existence of the hemorrhagic tendency ; for there is nothing in the 
character of the joint symptoms to distinguish the swelling from that pro- 
duced by other causes. 

Prognosis. — Hemophilia is a disease which is accompanied by serious 
danger to life. The exhaustion produced by repeated hemorrhages is so 
great that comparatively few of the patients reach adult years. Out of one 
hundred and fifty-two boys, the subjects of the hemorrhagic disposition, 
Grandidier found that only nineteen attained the age of twenty-one, and 
that more than half of the number died before completing their seventh 
year. Death usually occurs from hemorrhage, but some kinds of bleeding 
appear to be more unfavourable than others. Thus hemorrhage after ex- 
traction of a tooth is found to be especially dangerous ; obstinate epis- 
taxis is also to be viewed with grave apprehension ; indeed, to these two 
varieties of bleeding a large proportion of the deaths may be attributed. 

Children are said rarely to die from a first bleeding, and one profuse 
gush which causes fainting is thought to be more favourable than a slower 
and persistent oozing. Still, in any case w r e should speak very cautiously 



246 DISEASE IN CHILDKEN. 

of the future, whether immediate or remote ; for if the tendency be pro- 
nounced, the boy's chances of growing into manhood are not promising. 

Treatment. — In cases of haemophilia great care should be taken to pro- 
tect the child from all forms of injury. Vaccination has been seldom fol- 
lowed by dangerous bleeding ; but the operation should be performed, as 
Dr. Wickham Legg suggests, rather by scarification than by puncture. 
Surgical operations, even of the simplest kind, should be undertaken only 
as a last resource, and the extraction of a tooth should be expressly for- 
bidden. 

Constipation is likely to be particularly injurious to the subjects of 
haemophilia. Therefore it is very important to see that the bowels are 
properly relieved. The child should take a dose of gray powder with jala- 
pine every two or three weeks, followed by a saline ; and the latter, in the 
shape of Dinneford's magnesia or the granular citrate of magnesia, may be 
given regularly every week. The dietary should include a good proportion 
of vegetables ; and the white meats and fish are preferable to too much 
beef and mutton. In case any of the premonitory symptoms of haemor- 
rhage are observed, all meats should be at once forbidden, and a mercurial 
purge be administered, followed by a saline. Regular exercise should be 
enforced ; but boisterous games, such as cricket, foot-ball, etc., can only 
be indulged in at a great risk. 

When bleeding occurs, the treatment will depend upon the source of 
the haemorrhage. If this be at the surface, so that pressure can be brought 
to bear upon the part, as in the case of a cut or other injury, the applica- 
tion of a graduated compress, after careful cleaning of the wound, should 
be had recourse to. The local use of perchloride of iron, nitrate of silver, 
and other styptics, and of ice, is also recommended. In cases of sponta- 
neous haemorrhage astringents applied locally are our chief resource. In 
epistaxis the nasal passages must be first cleared out by injections of ice- 
cold w^ater. Afterwards the solution of perchloride of iron (of tlje strength 
of one drachm of the strong solution to an ounce of water) should be in- 
jected or sprayed into the nostrils. If this method fail, the anterior and 
posterior nares must be plugged. If the haemorrhage occur from the 
socket of a tooth, crystals of the perchloride of iron applied locally will 
sometimes arrest it ; or the alveolus may be packed with a graduated com- 
press soaked in the iron solution. Bleeding from the bowels usually comes 
from the lower part of the rectum, and can often be staunched by injec- 
tions of the iron solution (one or two drachms to the ounce). Bleeding 
from the gums is usually stopped by washes of tannin, alum, or rhatany ; 
and the child should be prevented if possible from encouraging the bleed- 
ing by sucking his gums. Iron and other styptics given internally seem 
to be of small value ; but ergot is stated to have proved of service. 

The subjects of this tendency should be warmly dressed and carefully 
protected from the cold. If possible their residence should be elsewhere 
than in cold, damp situations. The joint affection must be treated by per- 
fect rest, and cold or warm applications as are most agreeable to the patient. 
At a late stage blisters to the joint are said to be useful, but counter-irri- 
tation with the actual cautery is to be avoided. 



CHAPTER VI. 

PUEPURA. 

Purpura is a diseased condition in which extravasations of blood take place 
into the skin and the substance of the viscera, and blood may be poured 
out from many mucous surfaces and into the serous cavities. When the 
extravasation takes place into the skin it is called purpura simplex ; when 
the haemorrhage is more general the disease goes by the name of purpura 
hemorrhagica. Many acute forms of illness, febrile and other, are accom- 
panied by the ready escape of blood from the vessels. In the malignant 
forms of scarlatina, measles, small-pox, typhus fever, and diphtheria purpuric 
spots and haemorrhages are seldom absent ; and the same symptom is 
found in scurvy, and is occasionally met with in cases of Bright's disease, 
cirrhosis of the liver, leucocythemia, and valvular lesions of the heart. 
Strictly speaking, however, the term purpura is applied to a temporary 
hemorrhagic tendency unconnected with any of the acute specific diseases, 
and in which no morbid condition of organs, other than that due to the 
extravasation and its consequences, can be discovered. 

Causation. — Purpura is common in children, and appears in many cases 
to be a consequence of insanitary conditions and insufficient food. Still, 
that the disease may arise from other causes is shown by the well-nour- 
ished state and robust appearance of many of the subjects of this disorder. 
The haemorrhagic tendency is sometimes seen to come on quite suddenly 
without apparent cause in one member of a healthy family, the others 
who appear to be living in precisely the same conditions escaping alto- 
gether. Thus, a robust little boy, aged six years, one of eight healthy 
children and born of healthy parents without any history of haemorrhagic 
tendency, had himself been strong and well all his life with the exception 
of attacks of measles and whooping-cough during his second year. The 
boy suddenly began to bleed from the eyes, the nose, and the mouth, and 
soon developed all the symptoms of severe haemorrhagic purpura. In 
cases such as this the occurrence of the disease can never be traced to 
error in diet or insufficiency of vegetable food or milk. Sometimes pur- 
pura may come on as a sequel of an exhausting disease, such as scarlatina 
and typhoid fever, and I have known it to occur after a severe attack of 
croupous pneumonia. It is said, too, to be occasionally induced by the 
administration of iodide of potassium in weakly subjects, especially in 
those labouring under valvular disease of the heart. In many cases, how- 
ever, no antecedent condition of any kind can be discovered capable of 
explaining the sudden propensity to bleed. 

Morbid Anatomy. — In the skin the haemorrhage occurs in the rete mu- 
cosum and the papillary layer of the cutis, and also into the subcutaneous 
tissue. The submucous tissue is also often the seat of extravasation, and 
sometimes much blood is poured out from the surface of the mucous 
membrane. In this way, after death purple spots and extravasations of 



248 DISEASE IN CHILDREN. 

various sizes may be discovered beneath the mucous membrane of the 
mouth, gullet, stomach, and intestine both small and large. So also 
the serous surfaces and subserous tissues may suffer in the same way, 
and more or less copious extravasation may be found in the serous 
cavities — the pleura, the peritoneum, and the pericardium. The substance 
of organs is not unfrequently the seat of haemorrhage, and clots may form 
in the lungs, the heart, the kidneys, etc. Fatal apoplexy may also result 
from this cause. 

Pure purpura does not lead to disease of internal organs. If the 
anaemia be extreme, fatty degeneration of the muscular fibres of the heart 
and a similar condition of other viscera may be found ; but this is a conse- 
quence of the impoverished state of the blood induced by repeated haemor- 
rhages, and is only a secondary consequence of the hemorrhagic tendency. 
Amyloid and other degenerations found in the liver and elsewhere must 
be looked upon as a result with the purpura of a common cause. When 
bleeding is profuse and repeated the blood undergoes the changes inci- 
dent to an advanced stage of anaemia, the amount of haemoglobin is less- 
ened, and the red corpuscles are diminished in number as well as reduced 
in size. Unless the blood be impoverished by haemorrhages, no morbid 
change in the fluid can be detected. 

With regard to the pathology of the disease, the fault has been sup- 
posed to lie in some alteration of nutrition in the coats of the capillaries 
and smaller blood-vessels, so that they rupture readily under the pressure 
of the blood. This explanation may be a sufficient one when the purpura 
occurs in a cachectic subject, but it cannot apply to the sudden tendency 
to haemorrhages often manifested by a child whose health had been pre- 
viously satisfactory. Henoch suggests that in these cases the cause of the 
effusion may be a vaso-motor neurosis which gives rise to stasis in the 
blood, rupture of the wall of the capillaries, or migration of the blood 
globules from paralytic dilatation of the smallest vessels. 

Symptoms. — The spots may appear quite suddenly without previous 
signs of ill-health. Often, however, they are preceded by more or less 
aching of the limbs, slight feverishness, thirst, and symptoms of indiges- 
tion. The child has no appetite and is unwilling to exert himself, crying 
if obliged to walk, and complaining constantly of feeling tired. In some 
cases the appearance of the purpuric rash follows an attack of vomiting 
and diarrhoea. The spots are circular and of a brick-red or deep purple 
colour. They are not elevated above the surface, and pressure does not 
cause them to disappear. In size they vary from a pin's head to the 
diameter of half an inch or more, and their outline is distinctly defined. 
They may be so closely set as to be confluent. This is especially common 
about the instep and ankles. Often they are accompanied by marks like 
bruises due to extravasation into the subcutaneous tissue. These are 
bluish discolourations without defined margin, and may be accompanied 
by some swelling. They appear to be sometimes the consequence of in- 
significant injuries, for a gentle pinch or feeble blow will produce them. 
The purpuric spots come out in successive crops, and each, after going 
through the ordinary changes of colour peculiar to such haemorrhages, 
disappears in the course of a few days. At times the skin will be found 
to be nearly clear ; then another crop is discovered and the surface is 
thickly studded with them as before. They are usually most numerous 
on the limbs, but are found besides on the trunk, and sometimes, although 
rarely, on the face. Mixed up with the true purpuric spots may be 
wheals of urticaria, little patches of erythema papulatum or erythema 



PUKPURA — SYMPTOMS. 249 

nodosum, and occasionally blebs arise filled with bloody serum. Inspec- 
tion of the mouth will also often discover minute hemorrhagic extravasa- 
tions into the mucous membrane of the lips and cheeks. 

In the more acute form of the disease, when the general health has 
been previously satisfactory, the purpuric spots may be accompanied by 
cedematous swelling. The limbs then feel unusually firm and full and pit 
on pressure. Unless haemorrhage occurs from the urinary passages there 
is no albuminuria. 

A healthy little girl, aged five years, began to lose her appetite and 
complain of pains in the legs and knees. She was unwilling to take ex- 
ercise, and after walking for a short distance would say that her legs 
ached and ask to be carried up-stairs. These symptoms continued for 
two or three weeks without improvement. The child then became slightly 
feverish, her knees swelled, and purpuric spots appeared on the lower part 
of the body and on the legs. When seen on the sixth day the child looked 
well in the face and seemed cheerful. The spots were numerous on the 
lower limbs and varied from a pea to a fourpenny bit in size. They were 
brick-red in colour with a well-defined outline, and did not disappear on 
pressure with the finger. In addition to these spots there were larger 
patches, like bruises, of a greenish or yellowish colour. Both legs were 
uniformly swollen and felt very firm. They pitted distinctly on firm 
pressure. The knees were not swollen or tender at this time, but were 
said to have been very tender and painful. The skin covering the pop- 
liteal spaces was much ecchymosed. There had been no bleeding from 
the nose or other mucous tract. The heart-sounds were healthy. There 
was no albumen in the urine. 

The pains in the limbs usually continue after the spots have appeared, 
but subside in a few days. A return of the pain is sometimes found to 
precede the eruption of each successive crop of spots. The number of 
the crops varies. Sometimes there is only one. Usually, however, they 
are more numerous. Exercise seems to encourage the haemorrhages, and 
rest is therefore an important element in the treatment. In the simple 
form the disease is usually at an end in from one to three weeks. 

In simple purpura the extravasations are limited to the skin, but in 
the more severe form, called hcemorrhagic purpura, effusions of blood are 
noticed from other parts. The nose bleeds, and the haemorrhage may be 
so copious that it has to be arrested by mechanical means. Blood may be 
also discharged from the eyelids, the gums, the ears, the lungs, the 
stomach, the bowels, and the kidneys. Haematuria is a common conse- 
quence of hasmorrhagic purpura, and the amount of blood may be so 
copious from this source that the urine passed is of a deep red colour. 
The renal haemorrhage often occurs in one gush and then ceases entirely 
for a time, so that two successive discharges from the bladder may be of 
quite different characters — the first blood red, the second perfectly limpid 
and normal in appearance. Still, even if there be no naked-eye signs of 
blood in the water, the microscope will sometimes detect red corpuscles in 
the deposit. Haemorrhage from the bowels is seen as black clots at the 
bottom of the chamber-pan. It is rarely copious. Its appearance may be 
preceded by severe abdominal pain, which ceases when the blood is dis- 
charged from the bowels. Sometimes colicky pain occurs without being 
followed by intestinal haemorrhage. 

When pains in the joints are complained of, there may be some ten- 
derness and considerable swelling. This symptom is often spoken of as 
"rheumatism," and the disease is then called purpura rheumatwa. It 



250 DISEASE IN CHILDREN. 

seems probable, however, that sometimes, at any rate, the lesion is due not 
to rheumatic inflammation but to haemorrhage into or around the joint. If 
it arise from this cause the articular affection is more chronic than a 
rheumatic joint lesion, and remains confined to the part first attacked. 
There is no necessary discolouration of the skin. 

During the progress of the complaint the general symptoms are often 
indefinite. The appetite may be good or more or less impaired. A cer- 
tain amount of thirst is usually to be noticed. The liver may become 
much swollen from congestion, and the bowels are often confined. Usually, 
until the loss of blood has produced anaemia, the child complains only of 
aching and feeling tired. The temperature is often normal, but sometimes 
there is irregular pyrexia. The febrile heat does not, however, appear to 
bear any relation to the haemorrhage. I have not found it to precede or 
follow in any regular manner the flow of blood. 

A robust little boy, six years of age, was in his usual health when he 
suddenly began to bleed from the eyes, nose, and mouth. During the next 
month he continued to bleed every morning from the gums, and on three 
separate occasions had copious attacks of haemorrhage from the eyes and 
nose. An accidental cut on the finger also bled profusely for two hours. 
During all this month the boy was very thirsty, drinking any fluid he 
could get, even dirty water. 

On admission into the East London Children's Hospital the child 
seemed to be well nourished and had a healthy appearance, with a fair 
amount of colour in his face. His gums were not spongy. His face, body, 
and limbs were thickly covered with purpuric spots of a brownish-red 
colour, which did not fade on pressure. There were in addition large 
bruises on the right arm, the trunk, and the left thigh. There was no 
enlargement of the liver or spleen. The urine had a density of 1.029. It 
was clear, without sediment, and contained no albumen. The heart beat 
in the fifth interspace in the nipple line. At the apex the sounds were 
healthy but muffled, and a loud anaemic murmur was heard at the base. 

While in the hospital the patient had frequent haemorrhages from the 
nose, the mouth, the bowels, the kidneys, and into the skin. On one oc- 
casion he repeatedly retched and vomited large black clots of blood. He 
also complained much of abdominal pain, and passed large quantities of 
black blood from the bowels. This may, of course, have been blood 
poured out by the nasal fossae and swallowed ; but the haemorrhage was at 
any rate copious, and caused a marked blanching of the skin and much 
feebleness and languor. The boy's temperature varied considerably dur- 
ing his illness. He had irregular attacks of fever during which the tem- 
perature would rise to 101° or even higher, but the pyrexia did not always 
precede the gush of blood. If, however, there was fever when the haemor- 
rhage occurred, the first effect of the flow was to reduce the bodily heat 
to a subnormal level. 

The boy was treated first with iron, which seemed to have no effect 
upon the haemorrhages ; then with aperients, which produced at first a 
marked improvement ; later with iron and arsenic combined, under which 
he became rapidly convalescent. 

When anaemia occurs, the ordinary signs of debility are noticed. The 
child is pallid and feeble. He is restless and complains of headache, and 
his pulse is frequent and irritable. A systolic murmur can usually be de- 
tected at the base of the heart, and a loud venous hum is not uncom- 
monly heard at the upper part of the sternum. 

There may be some oedema of the ankles, and even of the limbs and 



PURPURA — SYMPTOMS — TREATMENT. 251 

face. In very severe forms of the disease the child may die from syncope 
or exhaustion, and sometimes death occurs in an attack of convulsions. 
Convulsions are due in rare cases to haemorrhage into the cranial cavity. 
Mr. Hallowes has reported the case of a boy between three and four years 
old, who had lived in a good air and been well fed. This lad, after being 
languid for one day, developed bruise-like patches on different parts of 
the body, and died on the third day after a convulsive attack followed by 
rigidity. At the autopsy extensive haemorrhage was found to have oc- 
curred into both ventricles with laceration of the brain substance. No rup- 
tured vessel could be found. 

Convulsions in purpura are not always the consequence of cerebral 
haemorrhage. A little girl three months old was under my care in the 
East London Children's Hospital for vomiting and diarrhoea. After these 
derangements had ceased a purpuric eruption developed on the body, and 
in a few days the child had an attack of convulsions and died. Here the 
brain was found to be unusually anaemic, and there were no signs of intra- 
cranial extravasation. These are, however, exceptional cases. In the 
child a fatal termination to the illness is rare. Usually after a longer or 
shorter period the haemorrhages cease, and the patient regains his colour 
and strength. 

The course of the disease is almost always irregular. The successive 
crops occur at uncertain intervals, and often the disease is thought to be 
cured when a sudden return of the extravasations shows us that the haem- 
orrhagic tendency is not yet overcome. 

Diagnosis. — Haemorrhagic purpura cannot be confounded with a ma- 
lignant form of exanthema, for the high fever and profound general suf- 
fering manifested in such dangerous cases are not present in the milder 
complaint. 

In scurvy there is always a history of privation or injudicious feeding ; 
the special symptoms follow upon a period of ill-health ; general tender- 
ness is a prominent feature ; and there is marked feebleness from the very 
first. In all these points the affection differs from purpura. Moreover, the 
treatment of the two diseases is different, and measures which are found 
to have an immediate influence upon the scorbutic condition are powerless 
to check the haemorrhagic tendency in purpura. 

In haemophilia, which is characterised by similar symptoms to those 
of purpura, the disease is a constitutional one and is almost always hered- 
itary ; the family tendency is well recognised, and the haemorrhage is 
usually first manifested as a consequence of a cut or injury. Moreover, 
the disposition to bleed is a chronic and permanent state, and is not a 
more or less acute condition which can be made to cease by appropriate 
remedies. 

Prognosis. — In simple uncomplicated purpura the prognosis is always 
favourable. In haemorrhagic purpura the disease is more serious ; but 
if the child be submitted early to treatment the illness rarely has a fatal 
issue. 

Treatment. — In all cases of purpura the child should be confined to 
his bed, as rest is of extreme importance in preventing repeated relapses 
of the disease. The two forms of purpura, viz., that which comes on 
quite suddenly in healthy children and that which attacks feeble or cachec- 
tic subjects, require a different method of treatment. In the first the 
old plan of energetic purgation is peculiarly valuable. Often in such cases 
a course of iron or other tonic is followed by no benefit whatever, while a 
few doses of some drastic aperient cause a prompt and final disappearance 



252 DISEASE IN CHILDEEK. 

of all hemorrhagic symptoms. This treatment is equally useful whether 
the complaint be of the simple or hemorrhagic variety, and may be em- 
ployed without fear even in cases where great anemia has been induced 
by the loss of blood. If the liver is found to be swollen from congestion, 
as sometimes happens, its size is quickly reduced by the purging. It is in 
these cases, perhaps, that the value of aperients is most strikingly illustra- 
ted ; but all cases of the acute variety of the complaint seem to be bene- 
fited by this method of treatment. The best form in which the aperient 
can be prescribed is a combination of the oil of turpentine with castor-oil. 
For a child six years old, two drachms of each may be given made into 
an emulsion with mucilage of tragacanth and flavoured with syrup of 
lemons and peppermint water. This draught should be taken before break- 
fast every morning, or on alternate mornings, according to the effect pro- 
duced. If the hemorrhage is not arrested in the course of a few days, iron 
and arsenic should be given in addition after each meal. A child of this age 
will take without inconvenience fifteen drops of the tincture of perchloride 
of iron and three or four of Fowler's solution, freely diluted, three times a 
day. Other treatment is also recommended. Werlhof, who first described 
the disease, relied upon quinine and dilute sulphuric acid. Ergot is pre- 
ferred by some, especially in cases where the hemorrhages are copious ; 
but this drug should be always given by the mouth and never hypodermi- 
cally by the injection of a solution of ergotin, as obstinate bleeding has 
been known to result from the puncture of the needle. 

Special hemorrhages must be treated by special means : epistaxis by 
the injection of iced water, or by the use of a spray of perchloride of iron. 
In using the spray the nasal passages must be first cleared out completely 
of clot by the injection of water. Afterwards two drachms of the strong 
perchloride of iron solution diluted with water to two ounces must be 
sprayed into the nostrils. Hemorrhage from the gums may be usually 
arrested by an alum gargle or the infusion of rhatany ; intestinal hemor- 
rhage by iced-water injections and the application of an ice-bag to the ab- 
domen. In hematuria gallic acid should be given. 

When the patient becomes anemic, stimulants (port wine or the St. 
Raphael tannin wine) must be given, and the child should take plenty of 
nutritious food. 

In the cachectic form of purpura aperients are less suitable. In these 
cases stimulants are required from the first, and the child should take 
food in small quantities at a time so as not to overtask his feeble digestive 
powers. Iron wine may be given with arsenic, and cod-liver oil is useful. 
As a special styptic turpentine in ten-minim doses is of service, taken 
every three or four hours, or an equal quantity of the liquid extract of ergot 
may be administered several times in the day. 



CHAPTER TIL 

SCURVY. 

Scukvy is a disease which is now rarely seen in its most pronounced form 
even in the adult, unless under circumstances of exceptional hardship and 
privation. As one of the diseases to which young children are liable it 
has been, until recent times, completely ignored. Lately, however, owing 
to the observations of Drs. Cheadle, Gee, T. Barlow, and others, a form of 
the malady has been recognised as an occasional consequence in infants 
of bad feeding and injudicious management. In such subjects the disease 
is commonly grafted upon rickets ; and there can be little doubt that it is 
this conjunction of the two maladies which constitutes the state described 
by Fiirst and others under the name of acute rickets. 

Causation. — A scorbutic taint which reveals itself by the milder phe- 
nomena of scurvy appears to be less uncommon than was at one time sup- 
posed amongst the out-patients of large hospitals. Dr. Eade, of Norwich, 
and Dr. Ralfe, of the London Hospital, have both met with such cases 
amongst their patients ; and Surgeon-General Moore has remarked upon 
the frequency with which similar symptoms can be detected amongst the 
inhabitants of certain districts in India. In all such cases bad or insuffi- 
cient food is no doubt the cause of the impoverished state of the system, 
especially the want of fresh meat, fresh milk, potatoes, and vegetables 
generally. In young children the causes appear to be very similar to those 
which have the power of setting up rickets, although they are not identi- 
cal with them. If an infant be fed with excess of starchy food and sup- 
plied with sweetened preserved milk instead of the fresh milk of the cow ; 
if he be dirty and neglected as to his person, and breathe habitually a 
close, foul air, the conditions are just those which are capable of setting- 
up the scorbutic state. An infant so brought up quickly begins to show 
signs of rickets, and may perhaps be found all at once to develop the 
symptoms of scurvy. That every badly fed child does not manifest similar 
phenomena is probably owing to the fact that many articles of diet are 
anti-scorbutic, although not anti-rachitic ; indeed some, while they pre- 
serve from scurvy, may actually aid in the production of rickets. Scurvy 
differs from rickets in not being a disease of general malnutrition. In 
the former the affection is due merely to the absence from the blood of 
some constituent whose presence is essential to health. In the latter the 
whole system suffers, and the condition is one of general impairment of 
nutrition from deficiency of wholesome food. Consequently as long as 
the indispensable element is supplied to the blood the p:itient does not be- 
come scorbutic, however well the diet may be adapted to favour the oc- 
currence of rickets. Thus a child fed largely upon potatoes may very 
probably grow rickety, but he will certainly escape scurvy. Again, in Eng- 
land fresh fruit, being cheap, is largely consumed by the children of the 
poor. Even babies in arms are allowed to nibble at an apple or a plum 



254 DISEASE IN CHILDREN. 

as soon as they are able to hold an object in their hands. During the 
summer months they get strawberries and gooseberries ; ^ in the au- 
tumn apples, pears, and plums ; and in the winter and spring oranges. 
By such means a scorbutic tendency is no doubt counteracted, but general 
nutrition is little improved ; indeed, it is not improbable that on account 
of the indigestion and acidity which such indulgences must necessa- 
rily excite at this early age the occurrence of rickets is actually pro- 
moted. 

The outbreak of scurvy often appears to be determined by some influ- 
ence which causes a temporary depression in the child's strength. Chil- 
dren who inherit a diathetic tendency are probably more prone than 
constitutionally healthy subjects to suffer readily from the want of milk 
and fresh and wholesome food. In many cases, however, it is noticed that 
the patient is enabled to resist for a long time the influence of a distinctly 
injurious dietary ; and it is only when the nutritive processes are brought 
to a sudden standstill by an attack of gastro-intestinal catarrh that scorbu- 
tic symptoms begin to be observed. 

Scurvy is not confined to the subjects of rickets, but most scorbutic 
children are found to be suffering from that disease. This is not to be 
wondered at, for the age at which rickets is most liable to occur is also 
that at which scurvy is chiefly found to prevail. The two affections are 
also, as has been said, induced by causes very similar in kind ; and the 
general impairment of nutrition of which rickets is the consequence no 
doubt renders the patient especially sensitive to the effects of a scurvy 
diet. In most of the recorded cases of scurvy in the young subject the 
patients have been under eighteen months old. 

Morbid Anatomy. — One of the most characteristic morbid changes in- 
duced by the disease is a copious extravasation of blood into the tissues 
of the limbs, especially of the thighs. The muscles themselves are usu- 
ally pale, but the tissues between them may be infiltrated with serum 
more or less blood-stained. Sometimes blood is extravasated into the 
substance of the muscles, but without any evident laceration of the fibres. 
The chief seat of the extravasation is between the periosteum and the bone. 
In many cases the investing membrane is found to be separated widely 
from the shaft of the bone, retaining its attachment merely at the epi- 
physes. It is, moreover, greatly thickened and deeply injected. Between 
it and the bone lies a large, loosely adherent blood-clot in which the bone 
is embedded. When the clot is cleared away the bone is found to be 
perfectly smooth, although bare of periosteum. Another common feature 
is a separation of the epiphyseal ends of the long bones. This separation 
is not at the line of union of the epiphysis, but in the shaft of the bone 
just below the point of junction. The osseous structure at the seat of 
fracture can be noticed to be particularly loose and spongy. It is impor- 
tant to remark that in all these cases where separation of periosteum has 
occurred no sign of caries or exfoliation of the bone is to be discovered. 
Nor does the extravasation of blood ever appear to end in suppuration. 
The shaft of the bone is curiously fragile and thinned. This atrophy is 
well seen in some cases in the ribs, which may appear to be reduced to 
the two bony plates by almost complete loss of their cancellous structure. 
Extravasation of blood never seems to take place into the articulations, as 
is seen in haemophilia ; for all the joints and tissues immediately connected 
with them are found to be healthy. 

The above changes in the bones and periosteum are common to all fatal 
cases of scurvy in the child. Mr. T. Smith's case exhibited at the Patho- 



SCURVY — MORBID ANATOMY — SYMPTOMS. 255 

logical Society of London in 1875-76, under the provisional name of 
" hemorrhagic periostitis," showed the above changes in both lower limbs. 
The parts principally involved were the thigh bones, but the bones of the 
legs were affected, although to a less extent. In Dr. T. Barlow's beautiful 
preparations shown at the Koyal Medical and Chirurgical Society in 1883, 
the same characters were observed. The effused blood has usually been 
found of a deep marone colour and coagulated. Of other organs the ab- 
dominal viscera are generally healthy in these cases. The same thing may 
be said of the chest ; but once or twice Dr. Barlow has found some effusion 
in the cavity of the pleura, and in Mr. T. Smith's case there was a small 
haemorrhage in the lung. Often no sponginess or inflammation of the 
gums is to be seen, but little haemorrhages have been noticed at the point 
of the gum in the situation of the up-coming teeth. Other small extravasa- 
tions may be present in the skin in various parts of the body. They may 
occur around the ribs, and may be discovered in the intestines and kidney. 

The above morbid characters can leave little doubt that these cases are 
rightly classed under the head of scurvy. It has been objected to this 
view that although the symptoms observed during the life of the child do 
not, as a rule, point to any very marked deterioration in the quality of the 
blood, the lesions noted after death are the later manifestations of the dis- 
ease, such, indeed, as occur in the adult only as a consequence of profound 
constitutional cachexia. Thus sub-periosteal haemorrhage, which is a late 
symptom in the adult, is produced early in the child ; and the affection of 
the gums, which is usually regarded as one of the earliest and most charac- 
teristic symptoms of scurvy, may be absent in the young subject altogether. 
To this it may be replied that cachexia is produced very rapidly in the 
infant by acute disease, and that in some cases of scurvy in the child an ex- 
treme degree of anaemia and debility has been reached. But granting that in 
many cases serious lesions have been discovered where the general symp- 
toms have been comparatively mild, this is not to be wondered at, consider- 
ing the age and peculiarities of the patient. In a blood disease such as 
scurvy it might almost be anticipated that the tissues chiefly affected 
would be those in which growth and development are making most active 
progress. At the age at which young infants are usually found to suffer no 
tissues or organs are undergoing more rapid changes than the long bones, 
especially those of the lower limbs ; and it is exactly in these situations 
that the more pronounced lesions are observed. On the other hand, in the 
maxillary bones ossification and development are practically at a standstill ; 
for the child being (as he almost always is) the subject of rickets, the jaws 
have ceased for the time to increase in size, and the evolution of the teeth 
is completely arrested. 

The cause of the deterioration of the blood in scurvy appears to be, 
not the mere absence of potash salts, as Dr. Garrod believed, but rather, 
as Dr. Buzzard supposes, the absence of these salts in combination with 
organic acids. Dr. Ralfe has still further developed the latter hypothesis. 
This observer is of opinion that the primary change depends on a general 
want of normal proportion between " the various acids, inorganic as well 
as organic, and bases found in the blood, by which the neutral salts, such 
as the chlorides, are either increased relatively at the expense of the alka- 
line salts " or these latter are absolutely decreased. He concludes that 
there is a diminution in the alkalinity of the blood, and that this produces 
dissolution of the blood-corpuscles and fatty degeneration of the muscles 
and of the secreting cells of the liver and kidneys. 

Symptoms. — Children in whom the symptoms of scurvy are noticed 



256 DISEASE IN CHILDREN. 

are often large, flabby infants between twelve and eighteen months old. 
They usually show the milder phenomena of rickets, such as profuse 
sweating about the head, lateness of dentition, enlargement of the ends of 
the long bones, and beading of the ribs. In such subjects the course of 
the scorbutic disease is as follows : The patient shows signs of unusual 
and extreme tenderness. He dreads being handled, cries if put upon his 
feet, and if he had been able to walk, is quite taken off his legs. Next he 
begins to suffer from pains which seem to be constant. The child lies 
moaning in his cot, and screams if touched or even approached. Very 
soon swelling is noticed of a limb, usually a thigh — one or both. The 
affected part is enlarged by a cylindrical swelling which although not ac- 
tually brawny to the touch is yet firmer than natural. In many cases it is 
distinctly cedematous, but it may not pit under the finger, although it 
often gives the sensation of containing infiltrated serosity. In the lower 
limb the swelling usually occupies the whole length of the thigh and often 
of the leg. There is no perceptible fluctuation, and no enlarged veins 
can be seen, but the tint of the skin is often livid or faintly lead-coloured, 
and in a case recorded by Fiirst its tint was red and' glistening. There is 
no effusion into the joints, but these are usually swollen from enlargement 
of the articular ends of the bones. The upper limbs are less affected than 
the lower. The forearm just above the wrist is here the part in which 
swelling is most commonly noticed. In such a case if the swelling is not 
extensive, it is difficult to distinguish it from the ordinary epiphyseal en- 
largement so commonly present in the rickety child. But besides the 
parts which have been mentioned, swellings from local periosteal extra- 
vasation may be found at the upper part of the humerus and on the 
shoulder-blades, and sometimes similar extravasations are noticed in the 
skin and subcutaneous tissue. Petechia, bruise-like patches, and even 
small blood-tumours may be met with. There appears also to be the 
same tendency to the formation of ulcerating sores on the cutaneous sur- 
face which has been remarked in cases of scurvy affecting the adult. In 
one of Dr. Cheadle's cases — a little boy aged sixteen months — there were 
two unhealthy looking sores seated the one on the right wrist, the other 
on the fore-finger. 

At first, when the swellings begin, the child keeps his limbs flexed, but 
later a new phenomenon is noticed. The patient ceases to flex his legs, 
and allows them to remain stretched out straight in the bed, as if he had 
lost all power of movement. It will now be noticed on examination that 
a soft crepitus can be detected in the neighbourhood of the joints from 
separation of the epiphyseal ends of the bones, and the wrist may drop 
from fracture of the carpal end of the radius. At this stage the joints 
can be examined without the child appearing to suffer pain from the move- 
ment of the articulations. 

In many of the cases in which the sjmrptoms are well marked, spongi- 
ness of the gums and other minor manifestations of the scorbutic taint are 
entirely absent. Sometimes, however, the gums are red and soft and 
gelatinous-looking, and may be so swollen as actually to protrude between 
the patient's lips. They bleed at the least touch. The swelling may ex- 
tend to the mucous membrane of the palate, and this may be so spongy as 
almost to touch the dorsum of the tongue when the mouth is open Dr. 
Cheadle has reported some cases in which the affection of the gums was 
unaccompanied by signs of deep-seated extravasation m the limbs, but the 
two conditions may be present together. The child appears at this time 
to be the subject of marked cachexia. He is sallow and very emaciated ; 



SCURYY — SYMPTOMS — DIAGNOSIS. 257 

his temperature is often raised, reaching to 101° or 102° in the evening ; 
his appetite is poor, and his bowels may be relaxed. Often profuse per- 
spirations are noticed. If the mucous membrane of the mouth or gums 
is affected, the breath has a most offensive odour. The weakness is usu- 
ally very great. The child ceases to be able to support himself in a sit- 
ting posture, and when placed in that position falls on to his side at once 
if left alone. The urine may contain albumen and sometimes is reddened 
with blood. The abdominal organs seem to be healthy, and no enlarge- 
ment can be detected of the liver or spleen. There may be cough, but the 
physical signs of the chest are usually normal, or consist merely in a few 
large bubbles heard here and there about the back. In one of Dr. Gee's 
cases— a child aged one year — a curious recession of the chest was noticed. 
At each inspiration the whole of the front sank inwards, the ribs bending 
on each side at a point much outside the costochondral articulation, and 
the breast-bone receding instead of protruding as in rickets. Dyspnoea 
is not, however, mentioned in other recorded cases of the disease in early 
life. 

As the illness progresses it is often found that the swelling first noticed 
begins after a time somewhat to subside, and another limb becomes affected 
in a similar way. Thus, in Flirst's case the earlier swellings appeared 
in the left femur and the tibiae of both liinbs. Next, enlargement was 
noticed in the right forearm, and afterwards in the left forearm and the 
right arm. At the time when these secondary swellings appeared the parts 
first affected began to recover, and the fever abated. Even after apparently 
complete recovery the disease is still liable to recur, under the innuenee, 
probably, of the same causes which provoked the original attack. Thus, in 
Mr. Thomas Smith's case the child was said to have suffered eleven months 
previously from like symptoms which had lasted over a period of two 
months. 

Fever is not always present in cases of scurvy in the child. Sometimes, 
as has been stated, the thermometer marks an elevation of 101", 102 c , or 
ever higher, but the disease may run its course without the occurrence of 
pyrexia. Still, if the hfemorrhagic effusion is great and the tension of the 
periosteum correspondingly severe, a certain amount of fever is usually to 
be noticed. 

When the patients recover, as they will usually do if suitable treat- 
ment is adopted in time, the temperature ialls, the tenderness subsides, the 
swellings disappear, the appetite improves, and the strength and colour re- 
turn. X degree of thickening is left at first around the bone at the site of 
the swelling, but this after a time is no longer to be detected. Even the 
separated epiphyses will, under favourable conditions, become again con- 
solidated with the shaft of the bone. 

Diagnosis. — In all cases where a young child presents symptoms of 
rickets, and it is discovered that his feeding and management have been 
such as to favour the special deterioration of the blood which gives rise to 
scurvy, the symptoms of that disease should be looked for. These always 
supervene upon a state of ill-health, and never occur, as is the case with 
purpura, in a child whose condition is not in other respects unsatisfactory. 
Exaggerated tenderness, even in a case of rickets, is a suspicious symptom. 
In rickets tenderness is confined to cases where the bone-changes and 
general features of the disease are pronounced. If the symptom is noticed 
in a child who, although showing signs of rickets, is evidently suffering 
from the disease only in a mild form, it points very decidedly to scurvy. 

When the swellings occur in the liinbs the great enlargement without 
17 



258 DISEASE IN CHILDREN. 

fluctuation, or redness, or local heat of skin, is unlike ordinary periostitis, 
and, indeed, this disease is not a recognized complication of rickets. If, 
then, the patient be suffering from rickets, the probability of the additional 
phenomena being due to the supervention of scurvy should be considered. 

In many cases, especially if separation of the epiphyseal ends of the 
bone has occurred, with the symptoms of pseudo-paralysis, the difficulty is 
to exclude syphilis ; and if, as may happen, there is a history of miscar- 
riages on the part of the mother, or of doubtful symptoms in the child 
himself shortly after birth, it may be impossible to exclude a syphilitic 
taint. Still, the diagnosis of scurvy may often be ventured upon. Syphilitic 
pseudo-paralysis is usually accompanied by enlargement of the spleen and 
all the signs of a profound syphilitic cachexia. The child is greatly wasted. 
He is hoarse and snuffles, the cranial bones have the characteristic thicken- 
ing, and the skin has the peculiar dry, parchment- like appearance so com- 
mon in the inherited disease. In scurvy the patients are not as a rule 
greatly emaciated. Often their general nutrition is fair ; and the special 
characteristics of syphilis are absent. If the gums are spongy or signs 
of haemorrhage can be noticed in the skin or elsewhere, the evidence is 
strongly in favour of scurvy. 

Prognosis. — If the child be seen in time and measures are at once taken 
to improve the quality of his food and supply the lacking constituents to 
his blood, recovery may usually be counted upon. When children die 
in this disease they die from exhaustion. Much will therefore depend 
upon those who are entrusted with the care of the child, for scurvy is one 
of the maladies of which the treatment consists almost entirely in vigilant 
and judicious nursing. 

Treatment. — In all cases of infantile scurvy it will be found that the 
child has been deprived of fresh milk and fed upon Swiss milk and other 
kinds of tinned food, which are deficient in the material necessary for 
maintaining all the constituents of the blood at a normal standard. An 
immediate change must therefore be made in his diet. He should be 
given fresh cow's milk, diluted, if necessary, with barley-water or thickened 
with a proportion of potato-gruel. If he be twelve months old raw mutton 
pounded in a mortar and strained through a fine sieve, may be given every 
other day alternating with raw meat-juice, 1 or if the meat be not well 
digested, meat-juice can be given every day. If the child refuse this food 
the juice may be sweetened with sugar, or what is much better with tur- 
nip or carrot. Orange-juice is well taken as a rule, even by young babies, 
and is a valuable anti-scorbutic. If the patient be in a very exhausted 
state, twenty or thirty drops of brandy can be given every three or four 
hours ; or he may have one or two teasj>oonfuls of burgundy or the St. 
Raphael Tannin wine, diluted with an equal proportion of water. At the 
same time care should be taken to furnish a proper supply of fresh air. If 
the weather be suitable the child may be taken out frequently lying at full 
length in a little carriage. If he be confined to the house, open windows 
should be insisted upon, every precaution being taken to keep the cot out 
of the line of direct draught. The best medicine is cod-liver oil. This 
may be given with a few drops of the tincture of perchloride of iron, or in 
a draught composed of three of four grains of the citrate of iron and qui- 
nine dissolved in a teaspoonful of lemon- juice, and sweetened with spirits, of 

1 To make raw meat juice : Put two ounces of lean raw mutton very finely minced 
into an earthen vessel, and pour upon the meat enough cold water to cover it. Stand 
inside the fender before the fire for two hours, then strain through a sieve. 



SCUEVY — PROGNOSIS — TREATMENT. 259 

chloroform. An occasional powder of rhubarb and aromatic chalk can be 
given if there is an unhealthy state of the bowels. 

When the gums are spongy and bleeding, they may be painted several 
times a day with a solution of glycerine of tannin and glycerine of carbolic 
acid, fifteen minims of each to the ounce. This application was used by 
Dr. Cheadle in his cases with the best results. For the swellings of the 
limbs Dr. Barlow recommends surrounding them with wet compresses 
thoroughly wrung out, and covered with dry cloths closely applied. An 
operation seems to be unnecessary, although Mr. Herbert Page has re- 
ported a case in which he made an incision through the periosteum and 
turned out the extravasated clots without ill consequences. Still, it seems 
probable, from the results in other cases, that eventual absorption of the 
blood will take place if the child be put under favourable conditions for 
recovery. If separation of the epiphyses has occurred, the limb must be 
kept perfectly quiet in splints. 



Part 5. 
DISEASES OF THE NERVOUS SYSTEM, 



CHAPTER I. 

GENERAL CONSIDERATIONS. 



The diseases of the Nervous System in childhood present many difficulties. 
In early life the excitability of the reflex centres is normally in excess ; and 
can even be heightened by causes which rapidly modify the general nutri- 
tion of the body. Consequently slight irritants may give rise to symptoms 
of tumult in the nervous system which are out of all proportion to the ap- 
parently trifling character of the lesion which has produced them. On 
account of this excessive irritability of the nervous system many patho- 
logical states in the child express themselves by convulsive movements 
which in the adult are accompanied by much less striking symptoms. In 
the young subject signs of nervous disturbance may arise quite indepen- 
dently of actual disease in the nervous centres ; and the apparent violence 
of the commotion is not influenced by the seat of the irritant, and bears 
no proportion to the severity of the lesion of which it is the expression. 
Indeed, the same violent spasmodic movements may be the consequence 
of lesions so various in situation and in gravity, that in a case where such 
symptoms are noticed it is often by no means easy to discover the position 
of the irritant or to say at first whether or not the nervous centres are free 
from disease. 

In children investigation of disease of the cerebro-spinal system is car- 
ried on by means exactly the same as are employed in the case of the adult. 
As, however, the young child cannot describe his sensations we have to 
trust much to objective symptoms, and are dependent upon the memory 
and observation of others for important information as to peculiarities of 
manner and changes in temper and disposition. 

Of the symptoms to which cerebral disease gives rise some are peculiar 
to a centric lesion, while others are present in every case of nervous dis- 
turbance, however it may have originated. In every variety of acute ill- 
ness in the young child the impressionable nervous system shows signs of 
distress. This is well seen in a case of acute indigestion. The skin be- 
comes burning hot ; the child is restless, cries and talks wildly ; he 
twitches and starts in his uneasy sleep and, if an infant, may be violently 



DISEASES OF THE NEKVOUS SYSTEM — SYMPTOMS. 261 

convulsed. These symptoms indicate nervous disturbance but are not dis- 
tinctive of cerebral lesion. So, again, a child may scream out with pain, 
and frequently carry his hand to his forehead or ear, without his headache 
being necessarily a sign of disease of the brain. 

There are other symptoms which are more directly indicative of 
cerebral origin ; but which may still be present without owing their rise 
to any discoverable lesion of the nervous centres. Thus, squinting is a 
sign which should always be viewed with great suspicion. It is frequently 
present in convulsions, whatever their cause, and may even continue after 
the nervous seizure is at an end without being necessarily a sign of any- 
thing more serious than derangement of function. Sometimes the defect 
becomes a permanent one, and yet after death from some accidental cause 
a post-mortem examination of the body discovers no lesion within the skull. 
Strabismus is not therefore necessarily a grave symptom. Still, it is so 
frequently a consequence of serious disease of the brain and membranes 
that its persistence after a convulsive attack should always give rise to un- 
easiness. An external squint, when it occurs without having been pre- 
ceded by spasmodic movements, is often a sign of pressure upon the cor- 
responding crus cerebri, and may be an early symptom of cerebral tumour. 
Strabismus may, however, occur as a consequence of hypermetropia ; and 
an intermittent squint is not unfrequently a symptom of chronic digestive 
derangement. Therefore, in all cases, careful search should be made for 
further evidence. In the case of cerebral tumour external squint is usually 
associated with ptosis and dilated pupils ; headache and vomiting will 
probably have been complained of ; there may be tremors or spasmodic 
movements in other muscles ; the sight is often impaired, and an ophthal- 
moscopic examination may reveal the presence of optic neuritis. 

Nystagmus, or small consensual oscillations of the eyeballs, very often 
indicates the presence of cerebral disease. It is common in the second 
and third stages of tubercular meningitis, and is then accompanied by 
severe and obvious symptoms of intra-cranial mischief. It is not un- 
frequently seen in chronic hydrocephalus and even in simple oedema of 
the brain, and is sometimes present as a consequence of cerebral atrophy. 
In cases of tumour of the brain nystagmus often precedes paralysis of the 
ocular muscles as an early symptom of a growth within the skull. Nys- 
tagmus is not, however, always a consequence of cerebral mischief. If it 
occurs in an infant in whom no other sign of nervous disturbance has 
been noticed it should suggest a congenital cataract ; for this lesion if left 
untreated is apt to induce oscillatory movements of the eyeball from alter- 
nate contractions of the recti and oblique muscles of the eye. Even in 
older children the symptom may be due to a congenital cataract which has 
been overlooked. In rare cases nystagmus is the consequence of a local 
chorea. 

The condition of the pupils should be always noted. During sleep in 
a healthy child the pupils are contracted but they dilate when the child 
wakes up. They are contracted in the early stage of meningitis, either 
the simple or tubercular form, and are also small if opium has been ad- 
ministered in too large quantities. In the later stage of meningitis and in 
many forms of cerebral disease the pupils are large and equal. If they are 
sluggish and contract imperfectly or not at all under the influence of light, 
the sign is a very grave one. If they are unequal on the two sides, the 
eyes themselves being perfectly free from disease, we can have little hope 
of the patient's recovery. 

Impairment or loss of sight is another symptom of importance. In 



262 DISEASE IN CHILDEEN. 

tumour of the brain it occurs early, and if combined with headache and 
vomiting is very characteristic of a cerebral growth. It is often observed 
in meningitis and in thrombosis of the cerebral sinuses. In these cases 
optic neuritis may perhaps be discovered by the ophthalmoscope. 

Delirium in the young baby is indicated by sudden screams, staring of 
the eyes, and a frightened look. In the older child by restlessness and 
random talking, as it is in the adult. The symptom is comparatively 
rarely the consequence of cerebral disease, although it may occur in cases 
of tubercular meningitis. As a rule, delirium in the child is evidence 
either of digestive derangement, of the febrile state, or of some altered 
condition of the blood such as obtains in the acute specific fevers. In ex- 
ceptional cases a transient delirium may be due to mere weakness, and 
may be seen on the subsidence of pyrexia at the end of an attack of acute 
febrile disease. In such a case it disappears at once when the child is 
spoken to and he answers perfectly rationally. Early and pronounced 
delirium, accompanied by a high temperature, is very commonly induced 
by croupous pneumonia ; and in any illness beginning with such symp- 
toms it is to this disease that our thoughts would naturally turn. 

Drowsiness, with dilated pupils, passing into stupor, is often a sign of 
intra-cranial mischief. After a fit of convulsions from reflex irritation, the 
child may be drowsy for an hour or two ; but unless congestion of the 
brain have supervened and effusion of fluid have taken place into the skull 
cavity, it is a symptom which in such a case soon passes away. If the fits 
are frequently repeated, and in the intervals the child is heavy and stupid, 
with large sluggish pupils ; if he takes no notice of familiar faces ; and 
especially if the temperature is high, and there are signs of headache, the 
case is probably one of meningitis. 

It must, however, be borne in mind that drowsiness approaching even 
to stupor may be present without being due to a cerebral lesion. Certain 
cases of pneumonia in the child are accompanied by stupor without the 
temperature being extraordinarily elevated, and may give rise to strong 
suspicions of cerebral disease. In such cases there is often little to attract 
attention to the chest, and all the symptoms point to the brain as the part 
affected. So, also, at the beginning of certain fevers, in uraemia, and even 
in some cases of severe gastric disturbance there may be great drowsiness 
and stupor, although there is no lesion of the brain. 

Loss of consciousness is not easy to detect in infants. The popular test 
is the capability of recognising a familiar face. If the baby no longer 
"takes notice," he is thought to be unconscious. But it must be remem- 
bered that impairment of sight is an early symptom of tumour of the 
brain, and may be present in other forms of cerebral disease. A child, 
therefore, may cease to recognise objects and faces because his sight and 
not his intelligence is defective. In all cases of unconsciousness or sup- 
posed unconsciousness it is important to notice if the child still takes liquid 
food. An infant, if his stupor is profound, or if he is suffering pain in 
the head or elsewhere, refuses his food ; while, if he is only stupid and 
drowsy, without being completely comatose, and is in no pain, he will 
often take his bottle with avidity. In cerebral haemorrhage and serous 
effusion a child sucks well from the bottle. When he is tortured with ear- 
ache or abdominal colic, he refuses all food while the pain lasts ; and a 
child suffering from meningitis can only be fed with great difficulty. 

Changes of temper should be always inquired for. At the beginning of 
many cerebral diseases the child often seems unaccountably wayward and 
capricious. He is fretful without cause, or spiteful, or sullen and morose. 



DISEASES OF THE NEEVOUS SYSTEM— SYMPTOMS. 263 

These symptoms are not, however, confined to cases of brain affection. 
The same change is often noticed in chronic abdominal derangements, and 
may be a symptom of epilepsy. 

Tremors, spasms, and paralysis are symptoms which derive their value 
from the connection in which they are found . 

Tremors are sometimes a result of mere weakness, as when they occur 
in the late period of typhoid fever. In such a case they are general, and 
the condition of the patient is one of extreme debility. When they result 
from cerebral disease they are often confined to one limb or to a group of 
muscles. In such a case, if they are repeated, and occur always in the 
same part, they should excite suspicions of tubercle of the brain. If 
rhythmical, they would suggest disseminated sclerosis, although this is a 
rare disease in childhood. 

Spasms or convulsive movements, both clonic (intermittent contractions) 
and tonic (persistent contractions) may be general or limited, like the 
tremors to one side of the body, to a group of muscles, or even to a single 
muscle. As a result of cerebral disease they are often so limited. Thus, 
if a child be subject to epileptiform convulsions which affect exclusively 
one-half of the body, some lesion (often a mass of cheesy matter) may be 
suspected in the opposite hemisphere of the brain. Still, a general con- 
vulsion, as has already been remarked at the beginning of this chapter, is 
not necessarily a sign of disease of the brain ; for in certain subjects a 
very trifling and passing irritant is able to induce it. This subject is 
treated of at length in a separate chapter (see Convulsions). 

Paralysis is commonly a consequence of disease of the brain or spinal 
cord ; but even this symptom may be sometimes referred to a less serious 
origin. Thus a temporary loss of power may follow a severe and pro- 
longed attack of convulsions, and is then attributed to exhaustion of nerve- 
force as a consequence of the seizure. This form of paralysis soon passes 
off. If it persist for a week or longer, it is probable that a lesion of the 
brain has actually occurred. Again, facial paralysis may be the result of 
causes acting upon the facial nerve after its point of exit from the tem- 
poral bone. An infant may be born paralysed on one side of his face 
from pressure of the forceps upon the trunk of the nerve ; and in older 
children rheumatic inflammation of the nerve-sheath from a chill may be 
followed by the same deformity. 

Even paralysis due to cerebral or spinal disease is not always perma- 
nent. "When the patient survives, power in the affected limbs is often 
recovered more or less completely. Thus, paralysis due to myelitis affect- 
ing the anterior cornua of the spinal cord (infantile spinal paralysis), at 
first very extensive, may be found in a few days or weeks to have limited 
itself to one limb, or even to a single muscle. Again, a paralysis from 
cerebral haemorrhage is often recovered from if the child survive ; and the 
mysterious form of paralysis which sometimes follows an attack of diph- 
theria generally passes off completely after a time. The loss of power is 
often very partial, and affects special muscles. In cases of cerebral tumour 
it may be limited to the muscles of the eye or face. 

The various forms of paralysis in children which result from clot, em- 
bolism, or other shock to the brain, are usually accompanied by aphasia. 
With regard to this symptom it may be noted that loss of speech is of less 
value in early life, as indicating the seat of the lesion, than it is held to be 
in the adult. Indeed, in the young subject aphasia may be present although 
the brain itself is free from disease. It must be remembered that in a child 
of five or six years old the power of talking is a comparatively recent ac- 



264 DISEASE IN CHILDREN. 

complishment, and that the utterance of any but the most simple phrase 
requires a distinct intellectual effort. In many weakened states of the 
body — whether produced by general disease or special injury to the cere- 
brum — the necessary effort cannot be made. Consequently, any shock to 
the system will in many children take away for a considerable time the 
faculty of articulate speech. 

Rigidity may be noticed in the affected parts. If the paralysis be per- 
manent, rigidity and contraction may eventually ensue. Rigidity, how- 
ever, is often a merely temporary phenomenon which affects various joints 
and comes and goes irregularly. This is often seen in cases of tubercular 
meningitis. Other forms of rigidity of the joints are seen in children. Tonic 
contractions may occur in the extremities from reflex disturbance of the 
nervous system (see page 274) ; the limbs may be the seat of spastic rigid- 
ity from disease of the spinal cord ; and in girls of ten or twelve years 
old the so-called hysterical contractions of the joints are by no means 
rare. 

A common form of rigidity is that which affects the muscles of the 
nucha and causes retraction of the head upon the shoulders. This symp- 
tom is a common one in cases of cerebral disease, and is a certain sign of 
intra-cranial lesion. Mere stiffness of the neck is not here referred to. 
This may be due to many causes, such as cervical caries, rheumatism, etc. 
In the retraction of the head so often induced by brain affection the head 
is drawn backwards upon the shoulders by rigidly contracted muscles at 
the back of the neck. This condition may be associated with rigidity of 
limbs, epileptiform fits, and hydrocephalus. It is often due to basic men- 
ingitis, and may be the consequencee of mere distention of the lateral 
ventricles with fluid. It is a grave symptom, although not necessarily a 
fatal one. Sometimes it is intermittent. 1 

Besides the symptoms connected especially with the brain, others de- 
rived from disturbance of distant organs may furnish signs not to be neg- 
lected of a cerebral origin. So great is the sympathy between the various 
organs of the body in early life that disease in the central nervous system 
is invariably associated with more or less general disorder of function. 

Vomiting is rarely absent in cases of cerebral disease. It happens not 
only after meals, but at other times ; and when retching occurs on an 
empty stomach, or is excited by merely raising the child up from his bed, 
it is a very characteristic symptom. Constipation, also, if obstinate, is a 
sign not without importance ; and if associated with vomiting, and occur- 
ring in a child in whom gradual failure of health has been noticed, is very 
suspicious of tubercular meningitis. Even the amount of tension of the 
abdominal wall is a matter not to be disregarded. In tubercular menin- 
gitis the softness and loss of elasticity of the parietes is sufficiently obvious 
to the touch, and at the same time the wall is depressed and retracted in a 
manner peculiar to this disease. 

The state of the breathing must be noticed. In many forms of brain 
lesion the respirations become very irregular, and this alteration of rhythm 
may be sometimes a very important sign. In tubercular meningitis, espe- 
cially, great irregularity of breathing, with frequent sighs and occasional 
long pauses during which the chest-walls are not seen to move, is a valuable 

1 It is important not to confound the involuntary contraction of the head from rigidly 
contracted muscles with the voluntary bending back oi the head which is seen in in- 
fants who are suffering from the pressure of an abscess upon the larynx. Such cases 
are accompanied by lividity of the face and urgent dyspnoea ; and a swelling can often 
be felt at the back of the pharynx. 



DISEASES OF THE NERVOUS SYSTEM— SYMPTOMS. 265 

aid to diagnosis when the nature of the disease is doubtful. There is a 
peculiar form of breathing, called from the writers who have drawn atten- 
tion to it the " Cheyne-Stokes " type, which, although not peculiar to cere- 
bral disease, is yet often noticed in such affections. It consists of a series 
of inspirations gradually increasing in depth and strength, and then as 
gr idually diminishing, until the movement of the chest- wall is hardly per- 
ceptible. There are many theories as to the pathology of this peculiar 
respiration. In most of them a supposed diminution in the excitability of 
the respiratory centre is a prominent feature. This type of breathing is 
often associated with headache and delirium, and may be found in disor- 
ders of the heart and kidneys as well as of the brain. Still, when it is 
found, whatever be the disease, some nervous complication is usually 
present. 

Information can also be derived from the state of the circulation. In 
the earlier period of meningitis the pulse often falls in frequency and at the 
same time becomes intermittent. If a child with a temperature of 102° 
have a pulse of 70°, especially if its rhythm be irregular, we should suspect 
the presence of tubercular meningitis. It must not be forgotten, however, 
that a slow pulse is not uncommon in children during convalescence from 
acute disease, and that this slow pulse may be irregular or even completely 
intermit at times, especially during sleep. We must not, therefore, attach 
too great importance to this symptom alone, unless the temperature be 
elevated, and the child's state be one to excite anxiety. 

Again, a remarkable modification in the vascularity of the skin is often 
seen in cases of tubercular meningitis. The child often flushes up sud- 
denly, and slight pressure upon the skin, especially that of the face, the 
abdomen, and the front of the thighs, produces a bright redness which re- 
mains for many minutes. This cerebral flush (called by Trousseau, who 
first drew attention to it, tache cerebrate), although perhaps more vivid and 
persistent in this disease, is yet not peculiar to tubercular meningitis. It 
may be often produced by gentle pressure in sensitive children, especially 
if they are the subjects of pyrexia. 

In all cases of paralysis in the child a careful examination should be 
made of the heart. Children, like their elders, are subject to embolisms, 
and if sudden hemiplegia occur in a child who suffers from valvular disease 
of the heart, we have reason to attribute the paralysis to this cause. 

Lastly, the state of the urine must not be forgotten. Coma and con- 
vulsions from Bright's disease are not uncommon in children. If, in such 
a case, oedema, however slight, be discovered, and an examination of the 
water reveals the presence of albumen, we can have little hesitation in 
attributing the nervous symptoms to a toxic cause. 

To make a complete examination of a young child in whom we suspect 
the existence of a cerebral lesion, all these points should be taken into con- 
sideration. In addition, it is important to study the face and expression 
of the patient, for by this means we may often exclude serious disease. A 
teething child who has just had a fit seldom looks ill — that is to say, his 
face has not the weary, haggard look which severe acute disease imprints 
upon it from the first. If the child's face looks pinched and distressed we 
may be sure, however apparently trifling the symptoms may be, that the 
case is a serious one. 

In connection with this subject of nervous symptoms in children it is 
important to remember that in them — even in children three and four 
years old — we must be prepared occasionally to find the peculiar function- 
al disorders of the nervous system which in the adult are called hys- 



266 DISEASE IN CHILDREN. 

teria. These disorders are found both amongst boys and girls, and have 
no necessary relation to puberty or the establishment of the catamenial 
function. Sensitive children, if frightened by the shock of a fall or other 
nervous impression, may be seized with convulsions of hysterical type and 
have various modifications of sensibility of the skin, combined, perhaps, 
with impairment or disorder of motor power. Aphonia, blindness, deafness, 
anaesthesia, analgesia, hyperesthesia, rigidities, and paralyses may be all 
met with from this cause. It is possible that in some of these cases the 
child is addicted to excessive masturbation, and some instances have been 
published in which there can be little doubt that debility and exhaustion 
of nerve-power induced by this means were the cause of the nervous dis- 
turbance. Often, however, there is no reason to suspect any such agency. 
The patient is a strong, healthy-looking child with firm muscles and well- 
developed limbs. In not a few such cases the derangement can be referred 
to a fright or other shock to the nervous system. 

Cases illustrating these various conditions are published from time to 
time in the medical journals, and all busy practitioners must occasionally 
meet with them. They are usually readily cured by the application of a 
moderate galvanic current. 

The diagnosis is not difficult. The derangement being purely func- 
tional, no nutritive changes can be detected. Thus the paraplegic child 
has full, firm limbs with no sign of muscular wasting. In the child who 
jorofesses that he cannot see, and gropes his way like a blind person, the 
retina shows no change to the ophthalmoscope, the cornea is bright, and the 
pupils contract noimally. Moreover, in almost all instances we may suspect 
the nature of the case, partly from the character of the symptoms them- 
selves, partly from the general appearance of the child, and partly from the 
absence of other signs of serious organic disease. 



CHAPTEE II. 

LARYNGISMUS STRIDULUS. 

Laeyngismus stkidulus (child-crowing, spasm of the glottis, internal con- 
vulsion) is very common in England. The complaint is a form of convul- 
sive seizure which is limited to the muscles of respiration. Sometimes it 
affects exclusively the muscles of the glottis ; in other cases it may impli- 
cate also the diaphragm and other muscles concerned in breathing. The 
disorder must not be confounded with laryngitis stridulosa, in which there 
is inflammation of the glottis with spasm superadded. Laryngismus, as it 
affects the vocal cords, is a pure spasm, arising, as other spasmodic attacks 
are so apt to do in the child, from reflex irritation. 

Causation. — The complaint may be met with under two different con- 
ditions : In new-born infants in whom no other deviation from health can 
be observed, and in rickety children between the ages of six or eight 
months and two years. 

The spasm appears to be predisposed to by foul air and hot, ill-venti- 
lated rooms. It is a remarkable and suggestive fact that the disorder is 
essentially a winter complaint, being prevalent when windows and doors 
are kept closed for the sake of warmth. It is rarely seen in summer, when 
every window is open to admit the air. Still, the derangement may occur 
without our being able to attribute it to any impurity in the air. In these 
cases it may be due to some special irritability of the reflex centres peculiar 
to the individual infant. 

Few writers now hold the opinion that laryngismus is the result of pres- 
sure upon the vagus or its branches by an enlarged thymus gland. Were 
this so, cases of laryngeal spasm would surely be much more numerous 
than they actually are. Moreover, M. Herard has reported that in six 
children who had died from this complaint, the size of the gland presented 
such striking variations that it was impossible to connect it with the pro- 
duction of the laryngismus from which they had suffered. It is equally 
improbable that pressure of any other kind set up on the pneumogastric or 
its recurrent branch can produce the disorder. The effects of such pressure 
in the case of enlarged bronchial glands are well known. Hoarseness of the 
voice and violent paroxysmal cough are early symptoms, and if spasm is 
induced it occurs, usually, at a late period, when the existence of the dis- 
ease is beyond a doubt. Spasm occurring alone without warning, and as 
suddenly subsiding without other symptoms being noticed, is not a char- 
acteristic of enlarged bronchial glands. 

The association of laryngismus with rickets is indisputable. It was 
first pointed out by Elsasser, and was dwelt upon by Sir William Jenner 
in his lectures on rickets in 1860, and more lately by Drs. Gee and Henoch. 
For many years I have paid attention to this matter, and can call to mind 
but few cases of laryngismus occurring after the age of six months in which 
the child was not rickety in some degree. It is important to remember, in in- 



26S DISEASE IN CHILDREN. 

vestigating this point, that the patients do not always show a marked degree 
of rickets. They may do so ; but as often, perhaps, as not, the child is fat, 
although pale and flabby — a big child, although a weak one. This connec- 
tion with rickets — a disease in which the irritability of the neivous centres 
is known to be exalted — is a strong argument in favour of the reflex origin 
of the spasm. It also serves to explain the cases where many children of a 
family have suffered in turn from the complaint ; for when a first child is 
rickety the others who are brought up under similar conditions usually be- 
come so too. Moreover, the tendency to laryngismus is often combined 
with a tendency to tonic and clonic spasm. In the same family one child 
may suffer from spasm of the glottis, another from general convulsions ; 
or in the same child attacks of laryngismus may alternate with general 
eclamptic seizures, or may even be complicated by them. That the latter 
disturbance is often a pure neurosis is universally conceded ; it seems, 
therefore, needlessly creating a difficulty to search for a different explana- 
tion for the former. Still, many other conditions have been said to be 
capable of causing the complaint. Various lesions of structure connected 
with the cerebro-spinal system have been discovered in children dying in 
a spasm, and in all of these cases a connection has been supposed to exist 
between the symptoms observed during life and the morbid appearances 
found in the dissecting-room. Thus the laryngeal trouble has been referred 
to chronic hydrocephalus, to exostosis in the skull cavity, or to actual 
pressure of the pillow upon a softened occiput. It seems highly probable 
that in all these cases the special pathological condition has been a pure 
coincidence, or at any rate has had only an indirect influence in inducing 
the nervous commotion. That no evident tissue change is needed to excite 
a perfect and even fatal spasm is proved by the numerous cases on record 
in which, after death in laryngismus from apncea, no lesion of the cerebro- 
spinal system or of the glottis could be detected. It is equally certain that 
under ordinary circumstances intracranial inflammations and effusions do 
not produce spasm of the glottis, and there is no evidence that pres- 
sure upon the substance of the brain or spinal cord will have any such 
effect. 

The exciting cause of the seizure is usually some peripheral irritant, as 
in the case of reflex convulsions. There may be disorder of the digestion 
or other irritation of the stomach or bowels, or a swollen, tense gum. The 
child may have been exposed to a sudden chill, and according to Henoch 
cold and catarrh of the air-passages are the most frequent source of this 
form of reflex irritation. In the few cases which have come under my notice 
of laryngismus attacking a child some time after birth where symptoms 
of rickets were completely absent, the spasms appeared to be due to slight 
laryngeal catarrh occurring in a nervous, sensitive child. I was asked some 
time ago to see a healthy baby, seven months old, who had cut two teeth 
and was cutting his upper incisors. The little boy was peculiarly preco- 
cious, and had the bright, intelligent face of one twice his age. There was 
no enlargement of the ends of the bones or other sign of rickets. The 
child was brought up at the breast, and his general health was good al- 
though his bowels were habitually costive. Some days before my visit the 
child had caught cold and had begun to cough. His voice also had been 
husky. Since that time he had alarmed his parents by occasionally mak- 
ing a noise in his throat "like the crowing of a cock." He did not suffer 
from dyspnoea, nor was there any lividity of the face. The sound was 
evidently due to a slight spasm of the larynx, which passed off almost im- 
mediately and seemed to cause little inconvenience to the infant himself. 



LARYNGISMUS STRIDULUS — CAUSATION — SYMPTOMS. 269 

The child's bowels were attended to and he was given half a grain of 
chloral twice a day. The symptom then soon subsided. 

In cases where there is great irritability of the nervous system cough 
or even swallowing may induce a paroxysm. Anything which frightens or 
irritates the patient may produce the same result. Thus in a young child 
who is subject to the attacks a fit of crying may bring on a seizure. 
Sometimes, again, the complaint is a relic of pertussis, the spasm remaining 
although the other symptoms of the disease have passed away. 

Symptoms. — We may often notice in rickety babies an occasional crow 
or croak in then- breathing which seems to cause them little or no incon- 
venience. In some children this symptom may continue for weeks and 
then disappear without being followed by anything more serious. In 
others, after it has continued for some time the child is suddenly seized 
with a decided attack of laryngismus stridulus. 

In a pronounced form of the seizure the child becomes all at once 
quite stiff and lies with his head back, his face congested and livid, his 
eyes staring, and his expression haggard and frightened. After a few 
seconds the spasm relaxes, the breath is drawn in with a crowing or 
hissing sound, and the attack is at an end. The child then looks pale and 
seems languid ; often he goes to sleep. 

In the more severe cases the spasm is repeated several times at short 
intervals. Still, actual closure of the glottis is seldom prolonged beyond 
a few seconds. There is no pyrexia, At the end of an attack the child 
often vomits, and sometimes he has a good fit of crying. 

The above is the simplest form of the complaint — that in which the 
spasm is limited to the muscles of the glottis. Even in these cases, how- 
ever, signs of tonic spasms in voluntary muscles are often to be detected. 
The fingers are forcibly clenched upon the thumbs, and the toes are flexed 
under the feet. This tendency to carpo-pedal spasms may continue 
between the attacks and even for some little time after the seizures have 
ceased to appear. The number of the spasms and the frequency with 
which they are repeated vary considerably in different cases. Generally 
the attacks are not very frequent at first, and sometimes after occurring 
several times they cease to appear. But if the child be the subject of 
marked rickets he seldom escapes so easily. The seizures, having once 
begun, sooner or later return. In the beginning they may be seen at 
comparatively rare intervals, and perhaps only after waking from sleep, 
or when the child is irritated or frightened ; but in bad cases they may 
recur so frequently that the patient is in constant peril. Dr. Eoberton 
has referred to a case in which the spasms were not absent for more than 
ten minutes, day or night, for ten months. Sometimes they cease com- 
pletely for a time, but return at the end of some weeks, or even months, 
when a sufficiently powerful exciting cause is again in operation. 

As an illustration of the length of time during which these attacks 
often continue, I may instance a little rickety boy, aged twenty months, 
who was an in-patient under my care in the East London Children's Hos- 
pital. Nine months before the child had had an attack of whooping-cough. 
After the cough had subsided the laryngeal spasms still continued, and 
were often repeated eight or nine times in the twenty-four hours. He 
had been treated as an out-patient three months before admission with 
much benefit, for the paroxysms had been greatly reduced in number, 
although they returned on the slightest provocation. If by any chance he 
coughed he always had an attack immediately. During the first few days 
after admission the child had three paroxysms daily. In these attacks, 



270 DISEASE IIS" CHILDREN. 

which came on quite suddenly, his lips turned blue, his breathing was 
excessively difficult, his inspirations were croupy, and his whole body 
was agitated, although there was no general convulsion. Then the spasm 
abruptly relaxed and he heaved a deep sigh. After the seizure he was 
always very pale, but the breathing was natural and there was no hoarse- 
ness. The child had all the signs of well-marked rickets. He had only 
six teeth; the joints were large; the fontanelle was open; the ribs were 
very soft and the lower part of the thoracic wall receded deeply at each 
breath. The spleen was enlarged, reaching nearly to the level of the navel. 
There were no signs of swelling of the bronchial glands. The child's 
bowels were loose and his motions very offensive. There was no fever. 
In this patient the spasmodic attacks were cured almost immediately by 
bathing him three times a day in cold water. 

A more complicated form of the complaint is that in which the spasm 
is not limited to the glottis, but involves also the diaphragm and other 
respiratory muscles. These cases assume much more the characters of 
general convulsions, for there is often more or less tonic spasm of the 
limbs, and consciousness may even be interfered with. Thus the child 
lies backwards with dusky face, half-opened eyelids, and upturned eyes ; 
breathing is laboured and inspiration difficult and crowing ; the diaphragm 
acts irregularly ; and there are often convulsive contractions of the mus- 
cles, causing profound .recession of the lower ribs and soft parts of the 
chest. Sometimes for a few seconds the glottis is completely closed ; the 
face then becomes lead-coloured, and the limbs are agitated by convulsive 
movements. According to Eilliet and Barthez, the pulse is small, frequent, 
and irregular, and the heart's action also irregular and tumultuous. If 
the child be markedly rickety a general eclamptic attack may supervene, 
or there may be tonic contractions of all the voluntary muscles, the body 
becoming stiff, the limbs contracted, and the fingers and toes forcibly 
flexed. 

In new-born infants, on account of the feebleness of the child — for it is 
in weakly or prematurely born infants only, as far as I have noticed, that 
laryngismus occurs so soon after birth — the symptoms are quieter. In 
the cases I have seen crowing-breathing was absent. The lips were no- 
ticed to turn blue and the face to become livid ; the baby stretched him- 
self out stiffly and remained for a few seconds perfectly motionless, with 
flexed fingers and toes. There was complete immobility of the respiratory 
muscles, and he seemed as if dead. Then he drew a deep sigh and the 
attack was over. In these cases the spasm appears to be seated in the dia- 
phragm and external muscles of respiration, leaving the glottis unaffected ; 
for no symptom is noticed of narrowing of the rima. Obstruction to 
breathing seems to be complete. The seizure is short and rarely lasts 
longer than five or at the most ten seconds. 

In an uncomplicated case of laryngismus stridulus, i.e., in a case where 
the complaint consists of pure muscular spasm, there is no fever. Some- 
times, however, laryngismus complicates an attack of pneumonia. The 
temperature is then high. These cases are very serious and usually end 
fatally. 

Even in an uncomplicated case death may ensue. If this happen during 
a paroxysm, the face assumes an expression of the utmost terror ; the eyes 
are widely open and suffused, the pupils are dilated, and the eyeballs seem 
to project ; the complexion grows more and more dusky, sweat breaks 
out on the forehead, and the pulse grows feeble and small. Inspiratory 
efforts are at first violent, then cease ; the heart stops, and the child falls 



LARYNGISMUS STRIDULUS — SYMPTOMS— DIAGNOSIS. 271 

back dead. Death may be preceded by general convulsions. This is the 
result of asphyxia from too long-continued spasm of the inspiratory mus- 
cles. According to Dr. J. Solis Cohen, incarceration of the epiglottis is 
apt to occur in the more violent paroxysms, and may produce death by 
suffocation. The epiglottis is drawn forcibly down by the spasmodic action 
of the ary-epiglottidean muscles, and its free edge is caught between the 
posterior face of the larynx and the wall of the pharynx, so as to cover the 
glottis like a lid and completely occlude it. In such cases it can be felt by 
the finger passed deeply into the child's throat. Sometimes death takes 
place still more suddenly, and the end then resembles an attack of fatal 
syncope. The dusky face assumes a ghastly pallid hue, the muscles gen- 
erally relax, and the patient is found to be dead. 

Li other instances, where the seizures have been violent and persistent, 
especially if they have been complicated by general convulsions, the child 
may die more slowly. In most of these cases extensive collapse takes 
place in the lungs. The spasmodic symptoms subside but the child's face 
continues dusky. His lips are blue, his nostrils work, he lies very quietly 
breathing with rapid, shallow inspirations which expand the chest very im- 
perfectly ; he gets more and more livid, and after some hours dies quietly 
or in a final convulsion. 

Sudden death from asphyxia may take place early, even it is said in the 
first attack. The slower death from collapse of the lung is seldom seen 
except in severe cases where the child is exhausted by repeated and violent 
paroxysms, or where the complaint has been complicated by general con- 
vulsions. In rickety children who are left untreated for that disease the 
spasms continue as long as the faulty nutrition to which the disorder is 
due remains unremedied. The seizures may therefore go on for months, 
or even years, when the parents are ignorant or careless, and the child is 
injudiciously reared. In ordinary cases the patient is treated early and 
soon recovers. Children after the second year rarely suffer from the com- 
plaint. I have, however, met with it once in a rickety little girl of four and 
a half years old. 

Diagnosis. — In new-born babies laryngismus, especially if it be of that 
variety which is manifested by spasm of the diaphragm and intercostal 
muscles without closure of the glottis, may be mistaken for infantile teta- 
nus. We may distinguish the two diseases by remarking that in laryngis- 
mus the temperature is normal, and that between the attacks the muscles 
are perfectly relaxed. This complete relaxation of the muscles is the most 
trustworthy distinguishing mark, for the temperature in very young chil- 
dren may be raised by many trifling and temporary conditions. Some- 
times, however, there may be a more serious complication that gives rise 
to pyrexia. Thus I once saw an infant of two weeks old who suffered from 
these attacks, and in whom there was pyrexia dependent upon pericarditis 
with copious effusion into the sac of the heart. 

In older children the case may be mistaken for laryngitis stridulosa. 
Here, too, the absence of fever is a very important distinction, if the dis- 
ease is quite uncomplicated. But children while cutting their teeth are 
subject to frequent elevations of temperature from the natural process of 
dentition ; and this in the subjects of rickets, who cut their teeth late, may 
be delayed far beyond the end of the second year. We should then be 
careful to satisfy ourselves that the gums are not swollen, arid that there 
is no stomatitis or other complication capable of giving rise to fever. 
Moreover, the history and course of the two diseases are different. In 
laryngismus the spasm comes on quite suddenly, lasts a few seconds or a 



272 DISEASE IN CHILDREN. 

minute or two, and then subsides. Laryngitis is preceded by cough and 
hoarseness ; the attacks of dyspnoea are much more prolonged, and even 
in the intervals the breathing is more or less oppressed, the voice hoarse, 
and the cough loud and clanging. Again, stridulous laryngitis is an acute 
disease, while laryngismus stridulus is apt to take on a very acute course. 
In laryngismus there are often tonic spasms or carpopedal contractions, and 
the disorder is often complicated by general convulsions. In laryngitis 
convulsions are rare and tonic contractions are very rarely seen. Lastly, 
laryngitis stridulosa, as a rule, attacks children after the age at which 
they are most susceptible to laryngismus, and is not common in infants 
under two years old. 

Prognosis. — In new-born infants the prospect is very serious, for the 
attacks at this early age are very apt to end fatally. Persistent lividity of 
the face or other sign of collajDse of the lung is a symptom of very dan- 
gerous import. 

In older children, if the spasm remains limited to the respiratory mus- 
cles, the prognosis is less serious than in cases where the convulsions, at 
first local, afterwards become general. The percentage of mortality has 
been put very high by some Avriters ; but statistics gathered from pub- 
lished cases alone are apt to be misleading, as only the worst cases are 
likely to be placed on record. The prognosis depends in great measure 
upon the strength of the child and the degree of rickets which may be 
present. If there be much softening of the ribs and consequent interfer- 
ence with respiration, there is great danger of jmhnonary collapse taking 
place, and the case is a very serious one. If, under these circumstances 
general convulsions ensue, the child's life is in very imminent danger. 
Even in the slightest cases we should speak guardedly of the patient's 
chances of recovery. 

Treatment. — If the child be seen during an attack, attempts should be 
made to excite vomiting by passing the finger into the fauces. Afterwards 
a sponge wrung out of hot water may be applied to the throat under the 
chin. According to M. Charon, who first proposed the remedy, the inha- 
lation of ammonia is almost invariably successful in arresting an attack. 
This physician advises all mothers whose children are subject to spasm of 
the glottis to carry a small bottle of ammonia — ordinary "smelling salts" 
■ — about with them. He relates the case of a lady whose child was always 
rapidly relieved by this means. Unfortunately one day the child was 
seized with an attack at a time when the remedy was not at hand, 
and while the mother was hurriedly searching for it the child fell back 
dead. 

If the suffocative spasm be very intense, it is well to thrust the finger 
deeply into the child's throat, so that the epiglottis, if incarcerated, as de- 
scribed by Dr. Cohen, may be released. The seizure, however, in most 
cases, is over so quickly that there is little time to adopt measures for 
abridging it. But we can at any rate take steps to prevent a return of the 
paroxysms. For this object cold water bathing is indisputably the most 
important and most immediately successful. The child should be placed 
naked in an empty bath or large basin, and be then rapidly sponged all 
over the body with cold water. In winter he may be made to sit in hot 
water during the process. The bath should be given three times a day. 
Very few cases of laryngismus will be found to resist this treatment. I 
have used it in obstinate cases, and to children suffering from rickets, with 
the most satisfactory results. Next to cold bathing fresh air is of the 
greatest service. The child, warmly dressed, should be taken regularly 



LARYNGISMUS STRIDULUS— TREATMENT. 273 

out of doors, and even in cold weather should spend many hours in the 
open air. 

While these measures are being carried out, search must be made for 
any source of irritation which may serve as an exciting cause of the 
spasms. Tense swollen gums should be lanced, the dietary must be re- 
constructed upon sound principles, and the condition of the digestive 
canal must be attended to. In many of these cases the bowels are loose 
with relaxed slimy motions. If this be so, a dose of rhubarb should be 
given, and the child should take for a few days five or six grains of bicar- 
bonate of soda dissolved in an aromatic water sweetened with glycerine. 
Of special drugs musk and belladonna are the most useful. The former 
can be given to a child of twelve months old in doses of one-third of a 
grain every six hours, and will be found to have a powerful influence in 
checking the tendency to spasm. Belladonna to be of service must be 
given in sufficient doses. A baby of twelve months old will take well fif- 
teen drops three times in the day. Mr. Stewart of Barnsley, speaks 
highly of chloral in the treatment of spasm of the glottis, and recom- 
mends two and a half grains to be given to a child of twelve months old 
three times a day. 

In new-born babies, for whom cold sponging is inadmissible, musk is a 
very important remedy. One-fourth of a grain can be given three times 
a day, suspended in mucilage. It can be combined with ten drops of tinc- 
ture of belladonna if thought desirable. 

If the child is markedly rickety, iron and cod-liver oil should be given 
as soon as the state of his digestive organs is sufficiently improved to make 
the use of the tonic desirable. Iron wine is, perhaps, the best form in 
which that drug can be administered, for the alcohol it contains is an ad- 
dition of great value to weakly children. Great care must be taken in 
these cases that the child is not overfed with farinaceous foods which con- 
tribute little to his general nutrition while they overload him with un- 
healthy fat. They are also very apt to turn acid in the stomach and favour 
catarrhal derangements. No mention has been made of bromide of po- 
tassium, for in this complaint I hold the drug to be of very inferior value, 
and place it far below musk in its powers as an antispasmodic. 
18 






CHAPTEE III. 

TONIC CONTRACTION OF THE EXTREMITIES. 

Tonic contraction of the extremities, or tetany, is sometimes met with in 
young children, most commonly in the subjects of reflex convulsions or 
laryngismus stridulus. The contraction occupies the muscles of the limbs, 
especially those of the hands and feet, and may be continuous, remittent, 
or intermittent. 

Causation. — Tonic contraction appears to be one of the many forms of 
reflex disturbance to which rickety and excitable children are so peculiarly 
prone. The disorder rarely attacks a sturdy subject. It is most commonly 
met with in young patients whose nutrition is imperfect either from in- 
judicious management or natural delicacy of constitution, and appears to 
be predisposed to or excited by digestive derangements and other forms 
of irritation. Thus a little girl of five years old, who had recovered under 
my own observation from tubercular peritonitis, but had remained very 
delicate and liable to gastric and intestinal troubles, one day swallowed a 
part of an orange. She was seized shortly afterwards with severe pains in 
the belly, and passed a few loose, unhealthy motions. At the same time 
the fingers became firmly clenched, with the thumbs inverted and the wrists 
flexed. In this state she remained for forty-eight hours, in spite of active 
treatment by injections and laxatives. At the end of this time a large 
enema brought away a mass of orange pulp. The child was at once re- 
lieved, and the rigid contractions of the muscles ceased from that moment. 
Similar instances have been recorded in which a constipated state of the 
bowels has been a cause of the phenomenon, and other sources of dis- 
turbance and excitement, such as pleurisy, pneumonia, diarrhoea, intestinal 
worms, the irritation of uric acid calculi, and teething have been quoted 
as exciting causes of this painful affection. The age at which children are 
most liable to be attacked is between the first and third year. The disor- 
der is said sometimes to affect young girls shortly before puberty, and in 
such cases is attributed on the continent of Europe, where tetany seems to 
be more common than in this country, to the influence of cold and damp. 

Symptoms. — A child who has been for some time in a weakly state, and 
is, perhaps, in the majority of cases, the subject of mild rickets, all at once 
cries with pain in the extremities, and it is noticed that these parts are 
contracted. Often the contraction is found to succeed to a fit of convul- 
sions or an attack of laryngeal spasm ; but it persists after these are at an 
end. The muscular spasm may affect both hands and feet, or be noticed 
first in the fingers, and spread thence to the hand and wrist, the ankle and 
the toes. When fully developed the hand is found to be flexed at the 
wrist, and the thumb to be firmly inverted into the palm. The fingers may 
be rigidly clenched upon the thumb, or slightly separated and perfectly 
straight except for some slight flexing of the last joint. The ankles are 
often extended and the toes firmly flexed. In a few cases redness and 
swelling in the "neighbourhood of the joints have been noticed. The con- 



TETANY— CAUSATION— DIAGNOSIS. 275 

traction in most cases seems to be painful. Infants cry repeatedly, and 
older children complain of pains shooting along the course of the nerves. 
The muscles are in a state of rigid contraction. In pronounced cases, not 
only can the muscles of the leg, such as the gastrocnemii and peroneii, and 
of the forearm be felt to be firm, but the act of manipulating them in- 
creases their tendency to become rigid. Pressure may even induce tonic 
contractions in muscles otherwise free from rigidity, such as the pectorals, 
the muscles of the neck, and those of the abdomen. In a severe case re- 
corded by Dr. Cheadle — in a boy two years old — even the muscles of the 
face were in a state of abnormal excitability, for irritation of the skin just 
in front of the left parotid region caused twitching of the orbicularis pal- 
pebrarum, the levator alee nasi, and the levator anguli oris. The same 
phenomenon was also seen, although to a less degree, on the right side of 
the face. There was, in addition, some difficulty in swallowing, especially 
when liquids were taken. 

"When the attacks follow a convulsive seizure they may be accompanied 
by a temporary paralysis, such as is a not uncommon consequence of 
eclampsia (see page 280). Sometimes the contractions are more exten- 
sive. Thus the muscles of the trunk are occasionally affected. Rilliet 
refers to the case of a delicate little girl, aged twelve years, in whom the 
tonic rigidity of the extremities was accompanied by opisthotonos with 
extreme retraction of the head, and at times intermittent contractions 
limited to the back were noticed, closely resembling tetanus in character ; 
but the jaws were not affected, as they invariably are in that disease. The 
disorder lasted for a month. In other cases, according to the same au- 
thority, the spasms may be more limited and affect the hip or one side of 
the neck. The disease appears to be more severe upon the continent of 
Europe than it is in England. In the milder form common in this coun- 
try the contractions are invariably bilateral, and affect the corresponding 
muscles of the two sides. As long as they continue, walking is impossible, 
and the child can hold nothing in his hand. In the slighter forms the 
contractions are remittent, and occasionally cease completely. In severe 
cases little variation is seen in the rigidity, and it persists during sleep. 
Even complete anaesthesia from chloroform produces no relaxation of the 
tonic spasm. Sensation is unaffected ; reflex excitability is normal ; the 
temperature is natural or even below the level of health and the child's 
intelligence remains perfect. In Dr. Cheadle's case the muscles responded 
well to both the continued and interrupted current. The tonic contractions 
are rarely the only nervous symptoms present. Often they alternate with 
other forms of nervous spasm. The child may be subject to laryngismus 
stridulus, or may be readily thrown into convulsions by any passing irrita- 
tion. In many cases, as has been said, the contractions succeed to some such 
form of nervous seizure, and sometimes an intermittent squint is noticed. 

In most cases, in addition, symptoms of intestinal or other derangement 
are present. Diarrhoea is one of the commonest of those symptoms ; and. 
indeed, the nervous disorder has been known to disappear as the condition 
of the bowels improved. The duration of tetany is very variable. It may 
last a few days or persist for weeks. It usually becomes intermittent before 
it finally disappears. After ceasing for a time it not unf requently returns. 

Diagnosis. — This form of nervous spasm is readily recognised. Tonic 
contractions occur in a child whose nutrition is impaired either from inju- 
dicious management, from gastro-intestinal derangement, or from the re- 
cent presence of acute disease. Often he is the subject of rickets, and has 
already shown a tendency to other forms of nervous derangement. Tetany 



276 DISEASE IN CHILDREN. 

is bilateral and symmetrical. It occasions no elevation of temperature and 
is accompanied by no clouding of the intellect. These qualities, combined 
with the tendency to nervous spasm, and the evident connection of the attack 
with some form of peripheral irritation, will serve to exclude cerebral dis- 
ease. In the severe form, which is accompanied by opisthotonos and tetan- 
oid spasms, the history of the attack, the normal temperature, and the en- 
tire absence of stiffness of the jaws will be sufficient to exclude tetanus. 

Prognosis. — Tetany is merely a symptom which has no gravity what- 
ever ; and the prospects of the patient's recovery of health depend upon 
causes quite independent of the nervous spasm. As the children in whom 
tetany occurs are often the subjects of a chronic intestinal derangement, 
and are in many cases distressed by frequent attacks of laryngismus stridu- 
lus, they may possibly succumb ; but in estimating the patient's chances 
of recovery the tonic rigidity of the extremities may be quite excluded 
from our calculations. 

Treatment. — Our first care in the treatment of this complaint must be 
to attend to any disordered condition which may be present interfering 
with nutrition, and acting as an irritant to the nervous system. Gastro- 
intestinal derangements must be checked ; constipated bowels must be re- 
lieved ; the diet must be regulated to suit the needs of the system (see 
Infantile Atrophy, Chronic Diarrhoea, etc. ) ; and if rickets be present, meas- 
ures must be taken at once to arrest its progress. In all cases, indeed, 
the general treatment recommended for laryngismus stridulus and rickets, 
viz., fresh air, good food, cleanliness, and the administration of iron wine 
and cod-liver oil, is of equal service in this disorder. Frictions and warm 
baths seem also to have a beneficial influence. 

In obstinate cases special steps are required to relieve the tonic rigid- 
ity. This form of spasm will often refuse to yield to measures which have 
the power of readily controlling the nervous disorders with which tetany 
is allied. Chloroform puts an immediate stop to an eclamptic seizure, 
but has no power of relaxing the rigidly contracted muscles of tetany ; 
and chloral which is so valuable in arresting the spasm in laryngismus 
stridulus is given in this neurosis without airy beneficial result. Bromide 
of potassium and musk appear to be equally useless. In Dr. Cheadle's 
case, before referred to, chloroform, chloral, and bromide of potassium were 
given without any success ; but the contractions yielded after the treat- 
ment had been changed to Calabar bean with cod-liver oil and iron wine. 
One thirty-sixth of a grain of the bean was given three times a day. The 
dose was gradually increased to one-eighth before any effect was produced. 
A notable diminution in the stiffness was then observed. Afterwards the 
dose w 7 as increased to one-fifth, later to one-fourth, and lastly to one-third 
of a grain three times a day. The boy was well seven weeks after begin- 
ning to take the remedy. 

Although the bean appears in this case to have had a decided influence 
over the spasm, it must be noted that the child began at the same time to 
take iron wine and cod-liver oil ; and that although the principal improve- 
ment occurred after the dose had been pushed to one-sixth of a grain, it 
followed two days after the important addition of pounded raw meat had 
been made to the child's diet. The Calabar bean, no doubt, deserves a 
more extended trial in these cases of tonic rigidity. Still, in the interest- 
ing case referred to it is doubtful what degree of improvement can be cor- 
rectly attributed to this remedy ; for the alcohol, the cod-liver oil, and the 
improved diet must have taken a sensible share in bringing about the 
child's recovery of health. 



CHAPTEE IV. 

CONVULSIONS. 

The commotion in the nervous system which goes by the name of eclamp- 
sia, or a fit of convulsions, is a common phenomenon in infancy, and is 
sometimes seen in early childhood. The seizure depends upon an ex- 
alted excitability of the reflex centres seated in the pons and medulla ob- 
longata, but is seldom attended by changes in those parts capable of being 
detected on examination of the dead body. The disturbance is essentially 
a symptom, and may be produced by a variety of causes. Irrespective, 
then, of the immediate danger to life, the phenomenon may be of serious 
moment or of trifling consequence according to the cause which has in- 
duced it. It is, therefore, of great importance to ascertain its mode of 
origin, for only by this means can we speak with any certainty as re- 
gards the influence which the attack is likely to have upon the future well- 
being of the child. 

It is during the first two years of life that the tendency to this form of 
nervous derangement is most active. At this period of childhood the ner- 
vous system of the infant, although immature, is undergoing rapid devel- 
opment, and the reflex centres respond briskly to every form of peripheral 
irritation. The tendency to eclampsia is not, however, confined to this 
age. Convulsions may even affect the infant in the womb. Early death 
of the foetus and premature labour can be sometimes attributed to this 
cause, and it is to this accident that some varieties of congenital deformity 
have been referred — those which are characterised by permanent contrac- 
tion of special muscles. After birth the proneness to convulsions may con- 
tinue for a longer or shorter time, according to the natural sensitiveness of 
the nervous system to external impressions. It is therefore much more 
persistent in some children than in others, and may endure in exceptional 
cases to the ninth or tenth year. 

Causation. — There are certain conditions which predispose a child to 
convulsions. Thus the liability to eclamptic seizures sometimes runs in 
families, so that all the children born of certain parents are found to suffer 
from these attacks. In other cases the tendency is confined to certain in- 
dividuals of the family, or even to one sex. Thus all the boys may have 
convulsions while the girls escape. Again, in rickets there is a special 
convulsive tendency which is very remarkable, and a large number of the 
cases of reflex convulsions are found to occur in children with this consti- 
tutional condition. When the predisposition exists Yerj slight causes — 
causes often so trifling as to escape recognition — may induce the attacks. 

Within certain limits the state of a child's nutrition does not appear to 
affect his susceptibility to convulsive seizures. A strong child and a weak 
one may be equally prone to suffer from this nervous disturbance. When, 
however, an infant is greatly reduced by long-continued interference with 
nutrition, a remarkable difference is noticed in his sensibility to nervous 
impressions. Not only is there no exaltation of reflex function, but the 



278 DISEASE IN CHILDREN. 

normal excitability of the reflex centres is diminished or annulled. There- 
fore in a child so enfeebled convulsions are seldom of reflex origin, but 
usually indicate grave cerebral disease. 

The exciting causes of the nervous commotion are very various : 

True reflex convulsions arise from peripheral irritation. Injuries to the 
skin from pricks, burns, and wounds ; irritation of the alimentary canal 
from indigestible food, hard faecal masses, or parasitic worms ; of the gums 
from inflammation and swelling during the cutting of a tooth ; of the ear 
from collections of wax, the presence of a foreign body in the auditory 
meatus, or inflammation of the tympanic cavity ; retention of urine ; sud- 
den chilling of the surface from exposure ; violent emotions, such as ter- 
ror — all these causes may set up convulsions in certain subjects. 

Irritation affecting the mucous membrane of the stomach and intestine, 
and according to some authors irritation within the ear, seem to be the 
most common exciting causes of reflex convulsions. In hand-fed babies 
indigestion is a familiar occurrence, and the disturbance set up by a mass 
of undissolved curd or other irritant may speedily culminate in an attack 
of eclampsia. Again, otitis is a more common disease of infancy than is 
usually supposed. It is often a direct consequence of dental irritation, 
and occurs with such frequenc}' as to constitute one of the more common 
complications of dentition. According to Dr. Woakes the inflamed and 
swollen gum is a source from which irritation is conveyed to the otic 
ganglion, and thence is deflected to the vessel supplying the tympanic 
membrane. Acute congestion of the membrane thus occasioned is a source 
of extreme pain ; and if the irritation persist, suppuration in the tympanic 
cavity may follow. Inflammatory tension of the gum alone may set up the 
eclamptic attack ; and the secondary disturbance in the ear is a fruitful 
source of such seizures. 

Eclamptic attacks are common in the child at the onset of acute illness, 
and correspond to the rigor which usually introduces the febrile move- 
ment in older persons. These seizures must not be attributed directly to 
the p}nrexia, for it is improbable that the mere elevation of temperature is 
sufficient to produce them. The more severe the attack and the younger 
and more impressible the patient, the more likely are convulsions to be 
seen. These attacks are seldom dangerous, but the eclamptic fits which 
occur at a later stage of the same diseases arise from a different cause and 
have a far graver meaning. 

Another class consists of the convulsions which are induced by imper- 
fect aeration of blood. These constitute the less serious attacks which 
sometimes arise in the course of pertussis after a prolonged paroxysm of 
cough, and often precede death in cases of extensive collapse of the lung. 

Congestion of the brain is often quoted as one of the causes of convul- 
sions, and no doubt fatal fits of eclampsia are frequently associated with a 
hypersemic state of ^ the cerebral vessels. The chief factor in such cases, 
both of the congestion and the fits, may, as Dr. Bastian has suggested, be 
minute embolisms or thromboses in the small arteries and capillaries of 
the brain. In the fatal convulsions which sometimes abruptly terminate 
an attack of whooping-cough congestion of the brain is generally present, 
and is often dependent in such cases upon thrombosis of the cranial sinuses. 

An exactly opposite state of the cerebral vessels may induce the same 
symptom. ^ The ansemia of brain which results from profuse hgemorrhage 
or exhausting discharges, such as an attack of acute diarrhoea, is often in- 
dicated by a convulsive seizure. It is, however, worthy of note that an 
equal degree of prostration slowly established by a chronic intestinal de- 



CONVULSIONS — CAUSATION — SYMPTOMS. 279 

rangement is not followed by the same consequences, the excitability of 
the nervous centres being then diminished instead of exalted. 

Lastly, toxic causes may induce convulsive seizures. Ursemic convul- 
sions belong to this class, and also the eclamptic attacks which are com- 
mon in children who live in malarious districts. Lead in the system may 
produce the same result. Infants seem to be very susceptible to the influ- 
ence of lead given medicinally. I have long ceased to make use of this 
remedy in the treatment of the diarrhoeas of young children, as I have 
several times seen convulsions follow its employment, and the attack has ap- 
peared to me in some cases to be directly excited by the use of this agent- 
Convulsions arising from cerebral disease have been omitted from the 
above classification, as partaking more of the nature of epileptic attacks 
than of true eclampsia. Reference must, however, be frequently made to 
them in discussing the subject of convulsive seizures, for it is of the ut- 
most importance in every case where a child is taken with a fit to be able 
to exclude centric causes from consideration. 

Symptoms. — The convulsive seizures may come on suddenly or be pre- 
ceded by symptoms of nervous excitability which are more or less obvious. 
Such phenomena are often called by nurses "inward fits." They are not 
invariably followed by a convulsion. Indeed, as a rule perhaps, they pass 
off after a time, especially if they are the consequence of digestive trouble, 
and the infant's placidity of manner returns. In other cases they become 
more and more pronounced, and culminate in an attack of eclamptic 
spasms. Thus the child is unusually disturbed in his sleep. He often 
starts and twitches. His eyelids may only partially close, and he wakes 
easily, starting up at the slightest touch. When awake he is restless and 
fretful. His senses seem unusually acute, so that loud noises frighten 
him. He changes colour frequently. His face has a curious expression, 
the ej^eballs are often directed upwards, and his thumbs may be twisted 
inwards across the palms. After these symptoms have continued for a 
variable time — often for several days — the child is all at once noticed to be 
unusually quiet. He stares with a peculiar fixed look, and his attention 
cannot be diverted to his toys. Then, suddenly, the fit begins. The child 
gets quite stiff, his head is retracted, his arms and legs are rigidly extended, 
his eyes are turned upwards, and he ceases entirely to breathe. In a few 
seconds the tonic rigidity is replaced by clonic spasms. The face becomes 
intensely congested, the eyelids are widely open, and the eyeballs are 
drawn upwards and to one side, and are twitched rapidly in different direc- 
tions. The muscles of the face work, the tongue may be seized and bit- 
ten by the teeth, and froth, perhaps tinged with blood, may appear upon 
the lips. The muscles of the limbs are thrown into the same spasmodic 
action, and more or less pronounced twitching affects the arms and legs, 
sometimes even down to the fingers and toes. Consciousness is completely 
lost. The skin is often covered with a profuse sweat, and in many cases 
the sphincters are relaxed, so that there is involuntary passage of urine and 
faeces. During the clonic spasms the breathing is not suspended, but 
there are jerking movements of the respiratory muscles. After some time 
the spasms become less violent. The face then changes from dusky red 
to a deathly pallor, the muscles relax, the child often gives a long sigh, 
and the attack is at an end. 

The spasmodic movements are usually general and involve both sides 
of the body, although one side is often more actively convulsed than the 
other. Sometimes they are partial, and may be limited to • one or both 
limbs on one side of the body, to the two arms, or even to one side of the 



280 DISEASE m CIIILDEEN. 

face. The eyes are almost always involved in the convulsion. The fit 
lasts for a time varying from a few minutes to several hours. In the 
longer fits there are intervals of more or less complete remission, and some- 
times the so-called fit consists of a series of eclamptic seizures with short 
intervals of quiet. In rare cases death takes place in the fit from asphyxia. 
As a rule, the child sleeps after the seizure has come to a close, and may 
wake to all appearance quite well. When the fit is repeated several times 
the child is drowsy for a time between the attacks, but the sleepiness 
passes off in a few hours. As long as any signs of abnormal excitability of 
the nervous system continue, and symptoms characteristic of the condition 
described as "inward fits "remain, we may anticipate a renewal of the con- 
vulsive seizures. It is not until all restlessness, starlings, twitchings, etc., 
have disappeared that our apprehensions can be laid aside. 

Some loss of motor power may be noticed after the fit is at an end. 
In cases of pure eclampsia this is a very temporary phenomenon, and 
only occurs when the seizures have been very violent and protracted. It 
is probably due to exhaustion of nervous power and disappears completely 
after a day or two. Any signs of permanent interference with nerve-force, 
such as local muscular weakness, contractions, or choreic movements, are 
usually taken to indicate some organic central cause for the convulsion. 
It is possible, however, that these symptoms may be the consequence of 
the seizure ; for severe cerebral congestion induced by intense and pro- 
tracted eclampsia may give rise to haemorrhage into the brain or arachnoid. 
Certainly I have known cases of convulsions occurring in children as a 
result of some temporary irritant to be followed by paralysis with contrac- 
tion of muscle, and have thought that in such cases the cerebral lesion 
might have been secondary to the eclamptic attack. There seems little rea- 
son to doubt that sometimes congestion of brain, with serous effusion suf- 
ficient in quantity to flatten the convolutions, may result from an eclamp- 
tic attack, and give rise to squinting, drowsiness, and death. 

A rickety little girl, aged twelve months, who had cut only two teeth, 
was quite well until January 7th, when she was weaned. She then became 
very fretful and vomited her food. At the same time an eruption of small 
red spots appeared on her arms and face. On January 9th the child had 
two fits, in which she " went stiff and worked her arms about." On Janu- 
ary 11th she had a third fit and then began to squint. 

When I saw the child, on January 17th, she was lying with her eyes 
closed ; the right eye was turned inwards with convergent squint ; the pu- 
pils were equally dilated, and acted well with light ; there w T as no discharge 
from either ear ; the face was pale, but flushed upon pressure of the skin ; 
there was no paralysis or contraction ; the thumbs were not twisted in- 
wards, nor were the toes flexed. When the abdomen was compressed 
the child made uneasy movements. She was evidently not unconscious, 
but seemed drowsy. The heart and lungs were healthy. The child was 
preparing to cut the upper incisors, and the gums were very full and 
tense. Pulse, 160, regular; respiration, of Cheyne-Stokes type, 40 ; tem- 
perature, 99°. 

The patient was ordered a mercurial purge, and bromide of potassium 
was given ; but the drowsiness deepened into stupor, and she died on 
January 19th. Her temperature rose every night to 101°. Half an hour 
before death it was 99.4°. 

On examination of the body the dura mater was noticed to be very 
tense, and the brain bulged through slits in the membrane. There was 
great venous congestion of the pia mater, and the convolutions were flat- 



CONVULSIONS— DIAGNOSIS. 281 

tened. On removing the brain about two ounces of sanguinolent fluid 
were left at the base of the skull, and on section much fluid escaped from 
the lateral ventricles. Nothing but congestion of the brain was noticed. 
There was no loss of consistence ; the membranes were not thickened, nor 
had they lost their pearly appearance ; there was no lymph effused, and no 
gray granulations could be detected. There was a mass of enlarged glands 
at the bifurcation of the trachea. The lungs and heart were healthy. 
Unfortunately the cranial sinuses were not opened. 

In this case it seems clear that the post-mortem appearances were sec- 
ondary to the convulsions. The nervous symptoms themselves seem to 
have been the consequence of reflex irritation from the state of the gums, 
combined with irritation of the stomach from unsuitable food, both oc- 
curring in a child of rickety constitution. The red spots spoken of were 
strophulous, resulting from the indigestion. 

Sometimes loss of speech and even imbecility have been known to follow 
upon an attack of convulsions. In such cases, no doubt, some profound 
cerebral lesion has induced the fit or been caused by it. 

Diagnosis. — In every case of convulsions we should examine the patient 
very carefully for signs of disease of the brain or its membranes, niore 
especially as the first question usually asked by the parents after their first 
excitement and alarm have subsided relates to the possibility of any affec- 
tion of the brain. In infants of twelve months old or under, if the child 
be fat and robust, the fit is in all probability reflex ; if he be under-nour- 
ished, weakly, and wasted, i.e., in that condition where all reflex excitabil- 
ity is practically in abeyance, the convulsion is no doubt the consequence 
of an intracranial lesion. In a weakly wasted infant by far the most com- 
mon cause of a convulsive seizure is general tuberculosis with secondary 
tubercular meningitis. 

The character of the fit itself will give some indication valuable in diag- 
nosis. Cerebral convulsions are often partial. Therefore, if the spasms are 
limited to one side of the body or one limb, we should search carefully for 
signs of cerebral disease. Paralysis of the face remaining after the end of 
an attack is indicative of a cerebral lesion. Thus, drawing of the mouth to 
one side, ptosis, or inequality of pupils are symptoms never seen in true 
uncomplicated eclampsia. A squint persisting after the convulsion has 
passed off must be regarded with anxiety ; for although not necessarily a 
grave symptom, it is often indicative of a serious lesion ; and if accompanied 
by signs of heaviness, or tendency to stupor, must be looked upon as an 
unfavourable omen. Again, convulsions, general or partial, without loss of 
consciousness, should lead us to suspect disease of the brain. Another im- 
portant symptom is the condition of the child after the attack. In true 
eclampsia consciousness is recovered quickly after the seizure ; and if any 
drowsiness remain, it is over in a few hours. Signs of persistent stupor or 
dulness of the senses would point to a cerebral lesion. Mere temporary 
loss of power in a limb is no proof of centric origin ; but if the paralysis 
continue longer than a few hours or a day or two, especially if contraction 
of muscle occur, we may conclude that some centric lesion, either primary 
or secondary, is present. Even if unmistakable evidence of a cerebral lesion 
is seen when the convulsion is at an end, it does not follow that the lesion 
was the cause of the fit. One consequence of eclamptic seizures is conges- 
tion of the brain ; and if the nervous attack be prolonged, serous effusions, 
and perhaps minute capillary hemorrhages, may occur and lead to alarming 
consequences. A case in which death took place from this cause has 
already been narrated. 



282 DISEASE IN CHILDREN. 

It lias been said that convulsions taking place at the end of the exan- 
themata and other febrile diseases are commonly attributed to cerebral 
congestion, although it seems probable from the observations of Dr. Bas- 
tion that embolic plugging of minute cerebral arteries takes a large share 
in their production. These attacks never come on except at an advanced 
period of the illness, when the state of the patient is evidently very serious ; 
and they quickly put an end to his sufferings. It is right here to mention 
that a fit may be the first sign of secondary tuberculosis. Tubercular 
meningitis, when it occurs in the course of an acute illness, has its own 
early symptoms masked by those proper to the primary disease, and only 
reveals its presence by the more violent phenomena which are character- 
istic of the third stage of the intracranial lesion. Appearing in this form 
— as a part of a general formation of the gray granulation all over the 
body — tubercular meningitis is not uncommon in babies of only a few 
months old. If, then, in a child of any age suffering from, an acute in- 
flammatory disease, such as an attack of acute catarrhal pneumonia, con- 
vulsions come on, we should strongly suspect tuberculosis ; and if the fit is 
followed by squinting and irregularity of pupils, with or without rigidity of 
joints, we can speak confidently of the existence of tubercular inflammation 
in the skull cavity. 

In cases where no serious cerebral lesion is suspected, it is important to 
distinguish an eclamptic attack from an epileptic seizure. At the time this 
is impossible, for the state of the patient requires all our attention, and if 
only to quiet the alarm of the relatives, it is urgent that something should 
be done. When, however, the subsidence of the spasms gives us leisure to 
make inquiries, we should try to discover some source of irritation to which 
the convulsion may be attributed. We should look for signs of rickets — - 
the condition which especially predisposes to eclamptic seizures — and in- 
quire for any convulsive tendency in the family. 

The age is of importance. Up to the time of completion of the first den- 
tition the disturbance is probably not epileptic ; and if the gums are tense 
or hot, or the child has lately swallowed some unsuitable food, we may 
feel satisfied that the case is one of pure eclampsia. Again, high fever is 
not a characteristic of epilepsy ; therefore, if there be pyrexia, the fit 
is probably reflex, or is a nervous disturbance announcing the onset 
of one of the exanthemata or of an acute disease. But irrespective of 
these considerations, under the age of two years epilepsy is rare, while 
reflex convulsions and the other forms of pure eclampsia are very com- 
mon. 

In older children it is more difficult, often it is quite impossible, to ex- 
clude epilepsy. If, however, the fit is a prolonged one, and lasts for an 
hour or more without intermission, we may conclude that the attack is 
eclamptic, for the duration of an epileptic seizure rarely exceeds ten min- 
utes, or at the most a quarter of an hour. When the urine can be obtained 
it should be always examined for albumen, as ursemic convulsions in chil- 
dren are not uncommon. For the same reason the whole body should be 
carefully inspected for signs of peeling of the skin, as ursemic convulsions 
towards the end of the desquamative stage of scarlatina are far from rare. 
The attack of scarlatina is sometimes so mild as to be overlooked by inat- 
tentive or unobservant parents ; and even if it be known to have occurred, 
the past illness may be looked upon as immaterial to the present disturb- 
ance, and may not be referred to. In all cases we must remember that 
after the age of three, or at the most four years, eclamptic attacks from 
reflex irritation are rare. Convulsions occurring in a child of this age, if 



CONVULSIONS— PROGNOSIS. 283 

not due to epilepsy or cerebral disease, are generally either ursemic or are 
premonitory of some acute febrile disease. 

As long as any cause can be discovered for the attack the fit is prob- 
ably eclamptic. It is the convulsion occurring without evident reason 
that is so suspicious of true epilepsy ; and if a child of four or five years 
old, or upwards, be visited while in apparent health by such a seizure, we are 
justified in fearing the beginning of epilepsy. It must be remembered, 
however, that convulsive seizures, at first eclamptic, may pass into true 
epilepsy. There is no doubt that this does happen in cases where there is 
a strong neurotic inheritance. Where there is no such predisposition I 
believe that epilepsy only follows in cases where the eclamptic attack has 
induced a secondary cerebral lesion. In such a case, although the first 
attack, or series of attacks, may have occurred as a result of some apprecia- 
ble cause, the after convulsions may arise without anything being discov- 
ered to serve as an explanation of the morbid phenomenon. 

Prognosis. — Eclampsia is a symptom which may be serious or not ac- 
cording to circumstances. In estimating the importance of the symptom 
we must consider the age of the child, the nature and severity of the at- 
tack, and the probable cause which has induced it. Infants of a few weeks 
old often die even from purely reflex convulsions if the seizures are vio- 
lent. Older children have a better chance of recovery. After the first 
few weeks of life much depends upon the cause of the attack. Purely 
reflex fits and the initial convulsions of acute disease rarely end otherwise 
than favourably. Again, the convulsions which arise from imperfect aera- 
tion of the blood, such as may occur in pertussis, are often recovered from ; 
but when the cause is collapse of the lung they are generally fatal. In 
pertussis, however, convulsions may be of several kinds, of which some are 
more serious than others. Those due to cerebral congestion and throm- 
bosis are invariably fatal. Eclampsia arising from congestion and anaemia 
of the brain are especially serious, because they usually take place when 
the patient is already in a state of great exhaustion. When convulsions 
occur towards the close of the eruptive stage of measles or scarlatina, they 
must be looked upon as a very dangerous symptom. Urcemic fits often 
pass away without producing serious consequences. Whatever be the 
cause of the attack, stertorous breathing, great lividity of the face with 
blueness of the nails, or a very rapid pulse should excite the gravest ap- 
prehensions. As a rule, the prospect becomes more unfavourable in pro- 
portion to the rapid succession of the eclamptic seizures and the severity 
of the attacks. The occurrence of a large flow of urine, according to M. 
Simon, is a sign of good omen, indicating that the convulsive movements 
are about to cease. 

In convulsions from cerebral disease it need not be said that prognosis 
is most unfavourable ; and if the fits are followed by stupor, squinting, or 
irregularity and sluggishness of the pupils, we can have little hope of the 
patient's recovery. 

The influence which the attack is likely to have upon future brain-de- 
velopment is a point of importance, and much anxiety is usually manifested 
on the subject by the child's relatives. In the commonest case, that in 
which a rickety child has a fit as a result of some trifling irritant, I be- 
lieve the attack to be usually unimportant ; and familiar as is the experi- 
ence, have rarely known the patient to suffer from any after ill-conse- 
quences. So in the case of the other forms of purely reflex convulsions, the 
eclamptic seizure is due to some temporary condition, or set of conditions, 
which may pass off, if the child survives, leaving the brain unharmed. If, 



284 DISEASE IN CHILDREN. 

however, the patient belong to a family in which nervous disorders are com- 
mon, convulsive seizures assume greater significance. If the attacks are 
often repeated, the prospect as regards the mental development of the child 
is unfavourable, for such cases may end in epilepsy or even idiocy. In all 
cases, too, where the convulsions are connected, either as cause or effect, 
with some intracranial lesion, and where they are followed by signs, more 
than merely temporary, of muscular weakness, there is no doubt that for 
the time the brain is injured by the illnes# In cases of recovery especial 
care would then have to be exercised in the child's education so as not to 
put too great a strain upon his faculties. 

Treatment. — When called to a case of convulsions the practitioner 
should lose no time in questioning the attendants, but should at once have 
the child placed in a warm bath of the temperature of 90° Fall., and apply 
sponges dipped in cold water to his head. This is the time-honoured 
remedy : it is certainly an innocent one : it may tend to quiet the nervous 
system, and it is one the efficacy of which is so generally recognised 
amongst the public, that it would be unwise to court unfavourable criti- 
cism by neglecting to employ it. The bath must not be continued too 
long. In ordinary cases the child should be allowed to remain in it for 
ten or twenty minutes, according to his age. If, however, the patient be 
an infant who has lately been reduced by an exhausting diarrhoea, he should 
not be allowed to remain more than two or three minutes in the warm 
water, and cold applications to the head may be dispensed with. If the 
convulsions have ceased when the case is first seen, the bath need not be 
used ; but we should not omit to have the child completely undressed, and 
then to see that he is placed, lightly covered, in a large cot, and that the 
room in which he lies is well ventilated and not too light. Care should 
be taken to unload the bowels by a large enema of soap and water ; and if 
the child be noticed to retch, his stomach may be relieved by a teaspoon- 
ful of ipecacuanha wine. In the case of a teething infant opinions differ 
as to the propriety of lancing the gums. There is no doubt that this op- 
eration is a useless one if employed with any hope of hastening the evolu- 
tion of the teeth ; but if the object be to relieve pain and tension, I con- 
sider the practice judicious, and never hesitate in such circumstances to 
have recourse to it. If it be desirable to remove all sources of irritation, 
surely such a source of irritation as a swollen and inflamed gum should 
not be disregarded. Lastly, if it can be discovered that the child has had 
pain in the ear, or if the tympanic membrane can be seen to be red, the 
ear should be fomented with hot water ; and if thought desirable a leech 
may be applied within the concha, the meatus being first plugged with 
cotton wool. 

If in spite of these measures the convulsions return, or signs are no- 
ticed of continued irritability of the nervous system, it is best to adminis- 
ter a dose of chloral. Two grains can be given to a child between six and 
twelve months old ; and if the patient be unable to swallow, half as much 
again may be administered by the rectum, dissolved in a few teaspoonfuls 
of water. If necessary the dose can be repeated several times a day. Bro- 
mide of ammonium, and belladonna, are also largely employed in these 
cases. The former may be given in three or four grain doses every two 
hours to a child between six and twelve months old ; the second in ten, 
fifteen, or twenty drop doses two or three times a day. In the convulsions 
of pertussis, where the spasm of the glottis is extreme, treatment by bro- 
mide of ammonium or potassium and belladonna is especially indicated. 
The bromides are well borne by quite young children, and we should not 



CONVULSIONS — TREATMENT. 285 

fear ill consequences from what may seem a very large dose. Chloroform 
also is often employed, but is decidedly inferior to chloral and much more 
troublesome. 

Nitrite of amyl is a very useful agent in arresting convulsions, and may 
be employed without fear of danger even in young infants. The remedy 
may be administered by the mouth or by inhalation. In the case of an 
infant of six to nine months old, one-fourth of a drop of the nitrite may 
be given in mucilage and glycerine three or four times a day ; and if the 
child be actually convulsed the inhalation of a drop on a morsel of lint 
will usually put a speedy end to the spasmodic movements. Even in cases 
where the convulsive seizures are due to cerebral disease the symptom may 
be controlled by the same means. Dr. A. E. Bridger has reported some 
cases in which this plan of treatment was followed by the utmost benefit 
as far as the muscular spasms were concerned ; for although the nitrite 
cannot of course exercise any remedial influence upon the centric disease, 
it is of no small advantage to be able to control a symptom which of all 
others is distressing to those to whom the patient is dear. Dr. Bridger 
found that it was necessary to increase the dose every twenty-four hours 
by about one-third. 

If the child have been lately the subject of exhausting discharges, warmth 
should be employed, and stimulants such as the brandy-and-egg mixture of 
the British Pharmacopoeia must be given energetically. 

If the convulsive attacks are followed by symptoms indicative of intra- 
cranial mischief, such as stupor, squinting, ptosis, etc., the child should be 
kept quiet and an ice-bag be applied to his head. In such cases the treat- 
ment must be conducted according to the conditions from which the con- 
vulsion is supposed to have arisen. 

When the convulsions have ceased, and signs of irritability of the ner- 
vous system are no longer to be observed, we must take steps to improve 
the general condition of the patient. His bowels should be attended 
to, and his diet carefully regulated. If rickets be present, it must be 
treated according to the directions laid down for the management of these 
cases. Most children in whom the convulsive tendency exists are benefited 
by iron wine and cod-liver oil, for their nutrition is usually at fault, and 
both the alcohol and the iron contained in the wine are beneficial, while 
the oil is of the utmost value in supplying nutritive deficiencies. Fresh 
air, too, is of extreme importance, and the child should be warmly dressed 
and taken regularly out of doors. 



CHAPTEE V. 

EPILEPSY. 

Epilepsy, a disease which may vary in severity from the most transient un- 
consciousness to violent convulsions and profound coma, is not uncommon 
in children. It has been estimated that nearly one-third of the cases met 
with in the adult have begun under the age of ten years. The malady is 
one of peculiar importance in early life, on account of its tendency to influ- 
ence injuriously the development of the brain. 

Causation. — In a large proportion of cases of epilepsy there is a hered- 
itary neurotic tendency. We often find a family history of epilepsy, of 
insanity, or of some form of nervous derangement. If this is the case on 
the side of both parents the child's prospect is a sad one, and in such 
families every child may be afflicted with some form of neurotic disturb- 
ance. Habitual intemperance in alcohol on the part of the father or 
mother is said to have a determining influence in the causation of epilepsy 
in the child. Lancereanx insists upon the importance of this cause, and 
states that a tendency to convulsions in their offspring is a common con- 
sequence of alcoholism in the parents. 

Cachectic conditions resulting from imperfect nutrition or disease, such 
as anaemia, chlorosis, and scrofula, have been said to favour the develop- 
ment of epilepsy ; but I can find no sufficient foundation for this statement. 
Rickets contributes largely to the occurrence of eclamptic attacks in in- 
fancy, but it does not, according to my experience, especially predispose 
to epilepsy unless there be strong hereditary neurotic tendency ; for when 
the disease passes off, as it will do readily if the causes exciting it be re- 
moved, the proneness to convulsive seizures also subsides. 

Amongst the exciting causes of epilepsy violent emotions, such as terror 
and fright, take a prominent place. Injuries, such as blows or falls upon 
the head, are answerable for many of the cases. It is also common to find 
the paroxysms attributed in the first place to eclamptic attacks occurring 
during childhood. It seems probable that in many cases of infantile con- 
vulsions some change takes place in the brain during the course of the fit, 
which afterwards induces a return of the seizures without discoverable 
cause. 

A bright, healthy little boy, aged eleven months, in whose family I 
could discover no neurotic history with the exception that his father and 
one of his uncles had had fits in infancy, was taken ill on August 31, 1870. 
Some pustules appeared on his legs and he was feverish. On the next 
morning he was seized with a convulsive fit which lasted with occasional 
intermissions for several hours and left him paralysed on the right side. 
During the next three days he remained in a drowsy state and was feverish 
at night. I saw him for the first time on September 4th. The child, a 
healthy-looking boy, had but three teeth. Still, although backward in this 
respect for his age, he showed no other sign of rickets. He was lying with 



EPILEPSY — CAUSATION — PATHOLOGY. 287 

closed eyes on his mother's lap. His pupils were equal and acted well 
with light ; his pulse 146, was regular in rhythm but not in force ; his 
breathing was irregular and interspersed with sighs, although without 
long pauses ; the temperature in the rectum was 101.6°. Both legs were 
covered from the knee to the ankle with an erysipelatous blush. Power 
over them was, however, being restored, for the child moved the right 
arm readily and the leg a little. At first they had been completely 
paralysed. His lungs and heart were healthy. The child seemed stupid 
but was not unconscious, for he watched a light passed before his eyes, 
and during examination of his chest cried and twisted himself about. 
When the teat of his feeding-bottle was given to him, he seized it eagerly 
and put it into his mouth. There was no paralysis of the face. 

The convulsions in this case had been evidently an initial symptom of 
the erysipelatous inflammation, and must have led to a small extravasation 
or other structural lesion in the brain ; for although the child quickly re- 
covered the use of his limbs, he became subject from that time to frequent 
slight fits, which were no doubt of an epileptic nature. They came on 
every two or three weeks without discoverable cause and lasted for one or 
two minutes. The boy was said to become suddenly very quiet ; then, in 
a moment, his cheeks flushed, his lips became purple, his eyes, although 
not exactly fixed, had an unnatural look, and he lost consciousness com- 
pletely. He did not twitch. When the fit came on he never fell, for his 
nurse seeing his sudden quiet and anticipating what was to follow always 
took him up in her arms. In spite of treatment these attacks became con- 
firmed, and in 1882 — the boy being then twelve years of age — were still 
going on. Occasionally he had a more perfect seizure, but usually the at- 
tacks were of the character which has been described. 

The above illustration I believe to be typical of a class, and am strongly 
of opinion that the origin of many cases of epilepsy in the child can be re- 
ferred to a similar accident. In other cases where there is a strong 
neurotic predisposition, and the gray matter of the brain is in a highly 
explosive state, it is possible that eclamptic attacks originally induced by 
some trifling irritant may become perpetuated as epileptic seizures without 
discoverable cause. Where no such predisposition exists, and no lesion is 
present in the brain, I know of no proof that convulsive seizures can be so 
perpetuated. 

Pathology. — No anatomical characters have been discovered by which 
the occurrence of epileptic attacks can be explained, and hence the nature 
of the disease is still a matter of speculation and doubt. The seizures 
have been attributed to both anaemia and congestion of the brain, the 
seat of the faulty action has been referred to the medulla oblongata and 
the upper part of the spinal cord, to the ganglia at the base of the brain, 
and to the cerebral convolutions. We have learned by experiment that 
lesions of the convolutions will induce muscular spasm, and that irritation 
of the cortex in the motor region will have the same effect. Nothnagel, 
too, has pointed out on the floor of the fourth ventricle a limited area, 
which he calls the " convulsion centre," on irritation of which all the 
voluntary muscles of the body are thrown into tonic and clonic spasms. 
Any or all of these parts may then be concerned in the production of an 
epileptic seizure. It can hardly be doubted that sometimes the convolu- 
tions may be the seat of the nervous discharge, for in a certain proportion 
of cases where at the beginning of the fit the patient is conscious of his 
condition, the discharge occurs in a centre of special sense ; also in cases 
where the aura is intellectual the hemispheres are probably at fault. 



288 DISEASE IN CHILDEEN. 

When the attack is distinctly reflex, the medulla oblongata and pons may 
contain the seat of diseased action ; and the fact that in all cases there is 
more violence of spasm on one side of the body than on the other seems 
to point to some controlling influence of the corpus striatum. 

The loss of consciousness has been explained to be the consequence of 
anaemia due to spasm of the cerebral arteries and capillaries, and caused 
by an extension of the discharge to the vaso-motor centre. According to 
another theory, consciousness is arrested as the result of an influence 
which radiates from the part affected to the sensorium. The after-symp- 
toms have been ascribed to carbonic acid poisoning from partial asphyxia, 
and this was long held to be a sufficient explanation, although lately doubts 
have been expressed as to its correctness. At present, however, no ex- 
planation has passed out of the region of hypothesis, and although dif- 
ferent theories may have different degrees of plausibility, none can be said 
to rest upon any very solid foundation. 

Symptoms. — The symptoms of epilepsy are very various. Although 
the convulsive movements are the part of the seizure which most forcibly 
attracts the attention, they are not essential to the nature of the disorder. 
The most characteristic feature is the loss of consciousness, and this, al- 
though often transient, is very rarely completely absent. A severe fit of 
epilepsy is much the same in the child that it is in the adult, and it will be 
unnecessary to describe minutely the characters of a seizure with which 
everyone must be familiar. The main features of the attack are similar to 
those already described as characteristic of eclampsia. It is preceded by 
a prodromal period of variable duration, in which some change is noted in 
the character, manner, or expression of the patient. The convulsion it- 
self seldom lasts longer than a few minutes. It is followed by a stage of 
coma, which is usually more protracted, bat sooner or later the child re- 
covers consciousness, although he may remain more or less stupid for 
some hours. Often recovery is marked by a profuse discharge of limpid 
urine. In many cases the onset of the fit is announced in the child, as it 
is in the adult, by an " aura." In others the first symptom is vertigo, or a 
sudden flushing or pallor, or a twitching of some particular muscle. What- 
ever this initial symptom may be, it is usually repeated before each 
attack. 

The more severe seizures (epilepsia gravior or haut mal) seldom appear 
in all their gravity when the child first becomes subject to the disease. 
They are usually preceded for months or years by a milder form of the 
affliction (epilepsia mitior, petit mal, or epileptic vertigo) which presents 
itself in very many different forms. 

In all varieties of epileptic vertigo, loss or clouding of the conscious- 
ness, which may be momentary, is the main feature, and is sometimes the 
only symptom. Thus, a child while engaged at his lessons or his play stops 
all at once in what he is doing and rests for a time perfectly quiet with 
dilated pupils and a strange fixed gaze ; then after a few seconds he re- 
covers himself and continues his occupation. Instead of being perfectly 
still, he may mutter some incoherent words or may perform some curious 
or unexpected act. Sometimes his face may lose its colour, or a twitch- 
ing may be noticed in one cheek, lip, or eyelid, or his head may be drawn 
to one side. In any case, when consciousness returns the child is quite 
ignorant of what has passed, and immediately continues the action in 
which he was engaged. In other instances he merely seems for the time 
to be puzzled and confused, and does not recognise his friends. In other 
cases, again, an ordinary peaceful and affectionate boy will suddenly do 



EPILEPSY— SYMPTOMS. 280 

some savage or spiteful act which is strangely foreign to his real disposi- 
tion, and which afterwards he is quite ignorant of having perpetrated. 

A little boy, aged twelve years, well nourished and healthy looking, 
had always been well until September, 1877, when he had an attack of 
pertussis. During this time he noticed that objects "looked small " to 
him for a moment. On recovery from the whooping-cough he returned 
to his day-school, and one evening, when doing his lessons, he seemed 
all at once to be " puzzled and confused, and did not know his father." 
Since then he had had some well-marked epileptic fits. 

The boy was brought to me in May, 1878. He then complained of 
slight but constant shooting pain in his right temple. I was told that he 
seldom had a genuine epileptic fit, but that he was very subject to attacks 
of mental aberration in which he did strangely spiteful things. The at- 
tacks were said to last from a few seconds to ten minutes and to end in a 
stupor of about a minute's duration. On recovery he was always quite 
ignorant that anything extraordinary had occurred. While standing be- 
fore me the boy had an epileptic seizure. He turned his face away over 
his left shoulder, remained for about thirty seconds perfectly motionless, 
and then fell backwards into his mother's arms. His face continued per- 
fectly placid and did not change colour. The eyes were closed, and when 
the lid was raised were seen to be turned upwards and to the right. 
There was a faint twitch noticed twice in the fingers of the right hand. 
The pulse was full and regular. After being in his mother's arms for 
about sixty seconds, he suddenly changed his position ; and then in 
another minute sat up, looked about him, and seemed quite recovered. 

Attacks of epileptic vertigo may come on suddenly, or maybe preceded 
by certain premonitory warnings, which soon come to be recognised by 
the friends as likely to be followed by a seizure. The warning may be 
a headache, a pain in the body or a limb, an attack of sickness, the con- 
traction or spasm of a muscle, or some curious change in the habits or 
disposition of the patient. It may precede the attack by several hours or 
a day or two. Sometimes it occurs without being followed by a fit. Epi- 
leptic vertigo often in time develops into the more pronounced form of 
the disease. Usually, as in the case above narrated, rare attacks of gen- 
uine epilepsy are separated by long intervals, during which the patient is 
afflicted by repeated seizures of the disease in a milder form. Often the 
severer fits occur only at night and may be thus overlooked for a time. 
Epileptic vertigo always recurs much more frequently than the genuine 
epileptic seizures, and the patient may suffer from many such attacks in 
the course of a single day. 

Between the attacks, whether of the graver or lighter form of the dis- 
ease, the child may seem perfectly well both in mind and body. He may 
be animated, intelligent, active, and seem in no way harmed by his afflic- 
tion. In other cases, especially if the attacks have dated from infancy, 
there is manifest interference with mental development, and the child 
may either have the manner and intelligence of one much younger than 
his age, or be dull and stupid even to idiocy. In the case already referred 
to — the little boy in whom the attacks began at the age of eleven months 
— when four years old he was intellectually on a level with a child of half 
his years. He sat on the floor and played with his toys with the manner 
of a baby, and had only learned to feed himself during the previous six 
months. Although he understood all that was said to him, he could only 
say a few words, and could not pronounce the letters s, 1, n, or m. At the 
age of five years he began to have daily lessons from a governess, who re- 
19 



290 DISEASE IN CHILDREN". 

ported him as " not difficult to teach." At twelve years of age the fits still 
continued, although they were, as a rule, mild and infrequent, and oc- 
curred at intervals of six weeks, two months, or longer. His father stated 
at this time, in answer to a letter making inquiry as to the boy's progress, 
that his mental power was below the average, and that the lad was far 
behind other boys of his age. 

The severe convulsions which occur at comparatively long intervals 
seem to have a less disastrous influence upon mental development than the 
milder epileptiform seizures which occur more frequently. Also, as has 
been before remarked, the age at which the seizures begin is a very impor- 
tant matter. If the child has been subject to them from before the com- 
pletion of the first year of life, his mental development is almost certain to 
be injuriously affected. 

Sometimes choreic movements occur in epileptic children, for there 
appears to be an association between the two diseases. A choreic child 
may develop epilepsy ; and a child subject to epileptic fits may become 
choreic. Dr. Growers has published some interesting cases illustrating this 
connection. 

Diagnosis. — An eclamptic attack in infancy and early childhood pre- 
sents exactly the same characters as a fit of genuine epilepsy, therefore it 
is very important to decide in every instance to which class of convulsive 
disease the attack is to be referred. This question has already been dis- 
cussed elsewhere (see page 282). 

Epileptic vertigo, when it takes the form of loss of consciousness with- 
out muscular spasm, is liable to be mistaken for an attack of syncope, 
especially in those cases where there is great pallor of the face. The 
seizures, indeed, are constantly spoken of by the parents as fainting fits, 
and we must be on our guard against this interpretation of the phenome- 
non. But syncope, although not uncommon in young people, is seldom 
seen except as a consequence of weakness, prolonged and exhausting dis- 
ease, or flatulent accumulation occurring in an anaemic child. Epileptic 
children are often robust and generally appear to be well nourished. 
Again, slight twitching of muscle, combined with complete loss of con- 
sciousness, would point to epilepsy. In syncope there are no twitchings, 
and if any muscular movement occur insensibility is not complete. 
Lastly, an epileptic attack is sudden, and when the child recovers he is 
ignorant of what has passed ; syncope is preceded by a very distinct sense 
of " faintness," and after the attack is at an end the patient is quite aware 
that he has been unconscious. 

Cases of cerebral disease with partial convulsions may be mistaken for 
this disorder, but in such cases there is a history differing widely from 
that of epilepsy, and other symptoms of cerebral disease are present. Be- 
sides, in the attack we do not find the peculiar interference with respiration 
which is so characteristic of an epileptic seizure. 

Even in the case of children it is necessary to be on our guard against 
the hysterical simulation of epileptic seizures both on the part of boys and 
girls. These false attacks can be usually recognized without difficulty. A 
boy, eleven years of age, was admitted into the East London Children's 
Hospital under the care of my colleague, Dr. Donkin, with a history of fits 
which were supposed to be epileptic. There was no neurotic tendency in 
the family, and the patient had always been healthy until the beginning of 
July, when he was noticed to look pale. He was said to have been exposed 
shortly before to a hot sun, and also to have received a heavy blow on the 
head of which for some time he seemed to feel the effects. On July 13th 



EPILEPSY — DIAGNOSIS — TREATMENT. 291 

he had a fit in the night, which was supposed to be a faint. During the 
next fortnight he suffered frequently from the attacks, often passing 
through as many as eight or nine in the day. The description given was 
that he felt giddy, fancied he saw "things going round him," made a clutch 
at some imaginary object, and then with a cry fell backwards. He was said 
to foam at the mouth, but not to bite his tongue although he clenched his 
teeth firmly ; to make convulsive movements with his arms as if fighting ; 
and sometimes to lie motionless with closed eyes. The mother thought he 
lost consciousness. The fit sometimes lasted half an hour. It was not fol- 
lowed by stupor, but the boy remained for some time oppressed and weary, 
and stammered when he attempted to talk. 

The first day he passed in the hospital he had eight attacks. In these 
he struck out with his arms, dashing his hands against the bars of his bed, 
but always striking with the fleshy part of the fist, never with the knuckles. 
He also kicked out with his feet as if keeping off some enemy. He threw 
back his head, and his face was much flushed by his exertions. It never 
became blue, nor was there any arrest of respirations. The eyelids were 
closed and he resisted opening them. When the conjunctiva was touched 
he winked. The pupils were not dilated. He did not injure his tongue 
even if he caught it between his teeth, and all his movements had a cer- 
tain voluntary character. There was no stage of tonic contraction. After 
the fit was over he lay down with closed eyes as if to sleep. 

On the second day a sharp galvanic current was applied to the boy's 
spine. After this experience he had no more attacks of convulsion. 

Epileptic fits which occur in the night only are often overlooked. In 
such cases the fact that a child suddenly begins to wet his bed at night is 
suspicious, and if a neurotic tendency exist in the family, the symptom 
should lead us to make further inquiries. 

Prognosis. — Cases where the attacks are well developed and occur infre- 
quently are more hopeful than the modified seizures which continually re- 
turn. Certainly they are more amenable to treatment. The age at which 
the affliction first manifests itself has less influence on the curability of the 
disorder than it is said to have at a later period of life. On account of 
the difficulty in following out these cases (for if no immediate improve- 
ment is noticed the patient is very apt to be lost sight of), my experience 
in this matter is too limited to enable me to speak positively ; but I am in- 
clined to believe that the appearance of the disease during the first two 
years of life is of less favourable import than when it begins later. There 
is no doubt that at this age its influence upon the mental development of 
the patient is more hurtful, especially as such early appearance implies in 
many cases a strong neurotic predisposition. 

The earlier treatment is begun after the onset of the disease the more 
favourable is the prognosis ; for while the affliction is still recent, we may 
have hopes of putting an end to the attacks. In confirmed cases, espe- 
cially if there is strong hereditary tendency, the child's prospect is but a 
gloomy one. 

Treatment. — It is so seldom possible to discover and remove the cause 
of epileptic seizures that little hope of curing the patient by this means can 
be entertained. It is not, however, the less desirable to relieve the child 
of all irritants, and to shield him from all influences which experience has 
shown to be injurious. Worms should be inquired for ; the state of the 
bowels should be regulated ; evil habits, if indulged in, should be con- 
trolled ; and the child's whole mode of life should be arranged according 
to the laws of health. All sources of excitement, whether in games, chil-- 



292 DISEASE IN CHILDREN. 

drens' parties, or public amusements, should be strictly forbidden ; and 
although monotony of life is to be carefully avoided, pastimes which do 
not over-excite the brain are to be preferred. The influence of quiet and 
of healthy recreation upon the disease is often seen in hospital patients. 
A child who has been admitted, with a history of severe epileptic seizures, 
occurring daily for months, may pass several weeks in the wards and. be 
eventually dismissed without any symptom of his disease having been 
detected. Careful gymnastic exercise is of value in promoting healthy 
change of tissue, but care should be taken to stop short of actual fatigue. 
"With the same object pursuits which occupy the mind, while they give 
employment to the hands should be encouraged, such as gardening and 
carpentering. A useful plan is to send, the child, under proper supervision, 
to a farm-house, where the tending and feeding of animals, and all the pur- 
suits incidental to healthy country life, will be found of infinite service to 
him. At the same time the patient should be kept under strict control ; 
any taste he may have for music, drawing, etc., should be cultivated ; and 
without fatiguing the mind by mental labour, much valuable instruction 
may be conveyed by conversation and the reading to him of suitable 
books. Dr. West recommends simple chants, such as are easily acquired, 
as a useful means of improving imperfect articulation, and suggests drill- 
ing to the accompaniment of music as valuable in correcting slovenliness 
of gait and aiding the child to regulate voluntary movement. 

The question of food is a very important one, as the frequency of recur- 
rence of the attacks maybe determined to some extent by the judgment 
with which his diet is selected. It is a generally recognised fact that an 
abundant meat diet is injurious to epileptics, for the brain-tissue which it 
helps to build up is of a more highly irritable composition than if a less 
stimulating dietary were enjoined. Butcher's meat must be taken spar- 
ingly, and the food should consist principally of milk, vegetables, poultry, 
game, and white fish. 

The drugs which I have found the most useful and which I believe to 
have a decided influence in checking the number and diminishing the se- 
verity of the attacks are strychnia, belladonna, and the bromides ' of ammo- 
nium and potassium. For a child five years of age I begin with two drops 
of liq. strychnise (P. B.) and twenty drops of tinct. belladonna? twice a day, 
and give at night half a drachm of bromide of potassium with camphor- 
water sweetened with simple syrup. This treatment should be continued 
for months together, increasing the dose of the strychnia solution by one 
drop and of the belladonna tincture by three drops every two weeks. In 
this way large doses of the drugs may be administered without danger. A 
little boy, four years of age, under my care took for a long time seventeen 
drops of the strychnia solution (or about one-seventh of a grain of the al- 
kaloid) twice a day with great benefit. Another child — a little girl nine 
years of age — by gradual addition to the strength of her medicine, reached 
one-fourth of a grain of strychnia twice in the day. An important part 
of the treatment consists in the administration of a weekly or bi-weekly 
aperient, for it is essential that the bowels be regularly relieved. Accu- 
mulation of fsecal matter is a powerful excitant of convulsive seizures in a 
child of epileptic tendencies. Moreover, the continued use of the bromide 



1 In all cases where the bromide salts are being taken, however small the dose, the 
practitioner must be prepared for the occurrence of the bromide rash. Some children 
have a curious sensitiveness to these salts. A few small doses of bromide of potassium 
will produce in such subjects an abundant eruption which, if their idiosyncrasy is not 
recognised, may excite considerable perplexity. 



EPILEPSY — TKEATMEISTT. 293 

salts tends in many children to produce constipation which may assume an 
obstinate character. In such cases it is useful to combine the strychnia 
mixture with one or two drachms of infusion of senna, so as to maintain a 
continued gentle action upon the bowels. The addition of chloral to the 
bromide is said to increase the efficacy of this treatment, and it has been 
stated that used in this combination a smaller proportion of the bromide 
is required to produce an equal effect. 

Besides the above remedies, other drugs have been employed in the 
treatment of this disease, such as the bromide and other salts of arsenic ; 
the sulphate, bromide, and oxide of zinc ; the oxide and nitrate of silver ; 
and ergot of rye. Very good results are sometimes obtained from the use 
of borax. This salt may be given in doses of one grain for each year of 
the child's life. Borax is best administered directly after food, for if given 
on an empty stomach it may excite vomiting. There is one disadvantage 
connected with the use of the remedy. In certain subjects the drug has a 
tendency to cause psoriasis which may prove obstinate. 

The attack may be sometimes arrested by the inhalation of chloroform. 
Any sudden shock is occasionally useful to attain the same object, such as 
applying ammonia to the nose or pouring cold water upon the head. Dr. 
Creighton Browne advocates the inhalation of nitrite of amyl. 



CHAPTER VI. 

MEGRIM. 

Megrim, or migraine, is a functional nervous disorder which gives rise 
to severe headache and other nervous phenomena, and often to nausea 
and bilious vomiting. The derangement is a not uncommon one in child- 
hood, especially amongst growing boys. Treatment is of peculiar impor- 
tance at this age, for if the complaint be allowed to continue and the 
attacks become frequent, the patient may be almost entirely incapacitated 
from pursuing his studies, and his education may suffer greatly in con- 
sequence. 

Causation. — In many cases megrim appears to be hereditary. We often 
find on inquiry that one or the other parent suffers or has suffered from 
the derangement, or that there is a tendency in the family to some form 
of nervous disease. Sometimes, however, this is not the case. The dis- 
order then appears to be acquired. In excitable children it may be in- 
duced by continued mental effort in crowded, ill-ventilated school-rooms, 
and the common practice of pressing forward the education at a very early 
age no doubt helps to engender the disposition to suffer from this com- 
plaint. 

Anaemia and debility, from which children often suffer soon after the 
second crop of teeth begin to make their appearance, probably also aid in 
the production of megrim, and an exhausting illness, such as typhoid fever, 
sometimes seems to predispose towards it. One of the most powerful of 
the exciting causes appears to be confinement in-doors combined with over- 
feeding in a weakly child. The complaint is much more common amongst 
the children of well-to-do parents than amongst the children of the poor, 
who pass so much of their time playing in the streets. 

Megrim is not seen in early childhood. It rarely begins to show itself 
before the beginning of the second dentition, at about the sixth year. I 
have, however, known it to occur in a little boy five years old. 

Pathology. — The view formerly held that the head symptoms were the 
consequence of gastric disturbance is now practically abandoned. Dr. 
Latham refers the source of the affection to the sympathetic nervous sys- 
tem. He believes that if by anxiety, fatigue, or other depressing cause, 
the regulating influence of the cerebro-spinal system of nerves is im- 
paired, the sympathetic system, no longer controlled, runs riot, causing 
contraction of the vessels and consequent anaemia of the brain. It is to 
this anaemia that he attributes the disorders of sensation which precede 
the cephalalgia. Afterwards the excitement of the sympathetic subsides 
and is followed by exhaustion, and the vessels becoming dilated produce 
the headache. 

Dr. Edward Living differs from this view. This authority ascribes all 
the phenomena to the irregular accumulation and discharge of nerve-force. 
He believes that a " nerve-storm traverses more or less of the sensory 



MEGRIM— SYMPTOMS. 295 

tract from the optic thalami to the ganglia of the vagus, or else radiates 
in the same tract from a focus in the neighbourhood of the quadrigeminal 
bodies." 

Symptoms. — The chief symptom of megrim is headache. Sometimes 
it appears to be the sole source of discomfort, but it is often preceded by 
a general feeling of illness and certain disorders of sensation. In many 
cases we are told that the child wakes up with a severe headache, and that 
this continues for several hours, during which he lies groaning and incapa- 
ble of any exertion either of mind or body. The pain in young subjects 
is more often bilateral than it is in older persons, and is comparatively 
seldom limited to one spot or one side of the head. It may extend across 
the forehead or over the top of the head or the occiput. It is of a very 
severe throbbing character, and is increased by light, by noise, or by 
movement. The child feels and looks excessively depressed. His face is 
pale and haggard. He cannot eat, and usually prefers to lie quietly on a 
sofa in a darkened room. His head is often hot, but his feet and hands 
feel cold to the touch, and he complains of feeling chilly and may shiver. 
The pulse is small and weak and may fall to 60 or 70. In exceptional 
cases the child feels sick and may vomit. 

The headache does not always occur in the early morning. Sometimes 
the patient wakes up in his usual health, and it is not until several hours 
afterwards that the pain begins. The cephalalgia is then often preceded 
by curious disorders of vision. Some children will say that objects look 
small to them, others that everything appears to be larger than natural. 
Sometimes stationary objects seem to be in movement, or there is partial 
insensibility of the retina, so that the patient cannot see the whole of an 
object at once. Thus in looking at his mother's face he may see only the 
right or the left side, not the whole. In addition to the sight, other 
senses may be affected. There may be noises in the head or impairment 
of hearing, or the taste or smell may be deficient. The child complains 
of unpleasant odours, or if offered milk remarks upon the peculiarity of 
its flavour. 

These earlier symptoms usually subside when the pain comes on. The 
headache lasts a variable time, from three or four to eight or ten hours, 
and then gradually subsides. As his suffering becomes relieved the child 
usually falls asleep and wakes well, but wearied and weak. The frequency 
with which the attacks come on varies in different subjects. Often they 
are periodical and return with remarkable regularity every week or fort- 
night. Sometimes a child after one attack has no return of the com- 
plaint for months. If boys at school suffer, the attacks are often very 
frequent. 

Some time ago I saw a school-boy, twelve or thirteen years of age, who 
was subject to daily headaches to such a degree as to be almost incapaci- 
tated from pursuing his education. The pain began in the morning on 
rising from bed and lasted all day, only subsiding towards the evening. It 
pervaded the whole of the head, and although not at first very severe, was 
made worse by exercise, by head-work, and by a bright light. It was not 
attended by sickness. If, as sometimes happened, the boy awoke free 
from pain, the cephalalgia came on in the middle of the day, and in this 
case did not subside as usual in the evening. The boy was subject about 
once a month to bilious headaches, but these he described as different to 
his ordinary pain. In the latter, objects always looked large to him. 

There was no doubt about the truth of the boy's statements. They 
were corroborated by his mother, who assured me that the severity of 



296 DISEASE IN CHILDREN. 

her son's suffering during his attacks was perfectly visible in his face. The 
boy himself was fond of his studies and seemed very anxious to be cured. 
He first took ten-grain guarana powders, but without relief. He was then 
ordered to take twice a day a dose of liq. strychnia (Til iij.) and liquid 
extract of ergot (TTj, x,), and in a few days the headaches had entirely 
ceased. 

In some cases, in addition to the cephalalgia pains apparently of a neu- 
ralgic character are complained of in the limbs. 

A well-grown boy, nine years old, was sent to me from the Isle of 
Wight by Dr. Gibson, with the history that for six months he had been 
suffering from frequent attacks of pain in the head and often in the legs. 
The boy used frequently to cry with pain which attacked him at night in 
the right hip and knee. He was noticed to drag the affected leg slightly 
in walking, and seemed to have a difficulty in placing the foot fairly by the 
side of the other. It was thought, too, that the leg was a little shortened. 
His temperature at that time was between 99° and 100°. The pain was 
not, however, confined to that limb. Sometimes it shifted to the other 
extremity, and sometimes was complained of in the back and shoulder. 
The temperature for a month was about 100°, but the boy seemed well 
except for the pains, and strongly objected to any restriction in his diet. 

When the patient came under my own notice he was in good condition 
and had a healthy appearance. The lungs and heart were normal, and the 
organs generally gave no sign of disease. The urine was acid, of specific 
gravity 1.014, and contained no albumen. No petechia or signs of bruis- 
ing were seen about the body. There was no swelling of any of the joints, 
nor any excess of fluid in the knees. The attacks of pain were said to 
come on at variable intervals. Often he woke in the morning with a se- 
vere frontal headache, but sometimes the cephalalgia came on during the 
day. It always lasted many hours. He rarely vomited. When the pain 
first began in the course of the day, he was noticed for some time before- 
hand to look white, with eyes " drawn," and his sight would be affected. 
He would see only half an object, or objects would look unnaturally small 
to him. In the limbs the pains were chiefly at this time behind the knees, 
but sometimes they affected the thighs and calves of the legs. They were 
increased by exercise, and he could not walk long without fatigue. His 
appetite was good and his bowels were regular. The boy was ordered to 
take two minims of liq. strychniee and fifteen of the liquid extract of 
ergot three times a day, and the nurse was directed, to employ vigorous 
frictions to his limbs before he went to bed. Under this treatment the 
distressing symptoms began to moderate, and as long as the boy remained 
in London— a period of several weeks — he had no return of the headache 
or pains in the limbs. Before his return home he was said to have greatly 
improved in his power of walking. 

Diagnosis. — Periodical attacks of headache, preceded by disorder of 
sight — these attacks lasting several hours and passing off completely, leav- 
ing the child well until the next recurrence — may almost always be ascribed 
to megrim. Children comparatively rarely suffer from dyspeptic head- 
aches, although sometimes during attacks of acid indigestion in young 
subjects dull pain in the temples and soreness of the eyeballs may be 
complained of. These attacks are, however, very different from megrim. 
The pain is much less intense and is preceded by symptoms of gastric de- 
rangement ; the tongue is foul ; the bowels are confined ; the patient looks 
heavy, and his complexion is usually sallow. In megrim the pain is intense 
and throbbing, the face is white, and vomiting, if it occur, is a late symp- 



MEGRIM — DIAGNOSIS — TREATMENT. 297 

torn, coming on towards the end of the attack. The attacks, too, often 
occur in the night, so that the patient, when he wakes up, finds the 
headache fully developed, although he had retired to rest in perfect 
health. 

Children who are much exposed to vitiated air, especially to air made 
unwholesome by gas-jets, often suffer from headaches, but in these cases 
the pain can be traced to the evident cause of the attack. Again, hyper- 
metropia is a not uncommon cause of cephalalgia in young people. This 
form of headache is not noticed until the education of the child is entered 
upon and he begins to pursue regular studies. He is then forced for 
some hours together to exert the full focussing power of his eyes in order 
to remedy his natural defect, and the consequent strain upon his muscles 
of accommodation gives rise to a frontal headache which is often very dis- 
tressing. Bat this headache always comes on at about the same time in 
the day, and is evidently connected with the act of reading. It ceases 
at once directly the hypermetropia is remedied by the use of suitable 
glasses. 

In headache due to cerebral disease, such as tumour of the brain, there 
are usually other symptoms connected with the brain which continue be- 
tween the attacks of paroxysmal suffering. Squint, or nystagmus, is often 
an early symptom, and persistent lesions of special sense soon begin to 
be observed. These are not limited to the seizures, but continue after the 
headache has subsided. 

Treatment. — During the actual attack the child should be allowed to 
lie quietly in a room shaded from a too bright light. If he be chilly a 
thin coverlet may be thrown over him, and if his feet feel cold they 
should be warmed by a hot-water bottle. The best remedy at this stage 
is the guarana powder, which is to be given in a dose of ten grains (to a 
child of ten years old) in a little sweetened water. This remedy is said 
to succeed best in cases where there are very distinct premonitory symp- 
toms, especially disorders of vision, but even in these cases the adminis- 
tration of the powder is often followed by no relief. Other remedies 
which sometimes have the effect of cutting short an attack are the bromide 
of potassium (gr. x.-xx ) with sal volatile, chloride of ammonium (gr. 
x.-xv.) with spirits of chloroform, and compound tincture of lavender. 
Various antispasmodics, as valerian, assafcetida, tincture of henbane, and 
the fetid spirits of ammonia, have also been recommended. In many 
cases — in most, perhaps, occurring in young subjects — the attack is very 
decidedly shortened by a dose (TT|, xv.-xx.) of the liquid extract of ergot 
given with spirits of chloroform in camphor-water. 

If sickness occur and prove obstinate, it may be often arrested by a 
saline effervescing draught containing a couple of drops of dilute hydro- 
cyanic acid (P. B.). 

After the attack is at an end the child should, if possible, avoid close 
rooms and head work, and should be made to spend as much of his time as 
possible in the open air. In the case of school-boys, however, it is impor- 
tant that their education should be proceeded with, and we must endeavour 
to arrest the tendency to the attacks without an y intermission of study. 
Few cases will be found to resist the combination of strychnia and extract 
of ergot already referred to in the treatment of the two cases which have 
been narrated. I was led to employ these remedies in this complaint from 
noticing their useful effects in some cases of epilepsy, and since beginning 
to treat megrim in the young subject by this method I have met with very 
few obstinate cases. Often from the time of beginning to take the 



298 DISEASE IN" CHILD REN. 

medicine the attacks have ceased altogether. I usually order two or three 
drops of the strychnia solution (P. B.) and ten or fifteen of the liquid 
extract of ergot with spirits of chloroform to be taken three times a day. 
I believe the combination of the two drugs to be more efficacious than 
either given alone, but in some cases strychnia given with iron has been 
found of value. 

The child's bowels must be kept regular with some mild aperient, such 
as the compound liquorice powder, and the diet should be regulated, 
taking care that he does not take an excess of sweets or fruit. 






CHAPTER Til. 

CHOREA. 

Chorea is essentially a disease of the second dentition ; for although it is 
occasionally met with in children under live years of age, and sometimes 
even in adults, yet an enormous majority of the cases are found between 
the ages of five and fifteen years. 

Causation. — Children who are likely to be attacked by this complaint 
are those in whose family there is a tendency to neurotic disease, and who, 
perhaps as a consequence of this tendency, are born delicate and sensitive, 
with a highly impressionable nervous system. Perhaps the mother may 
herself in childhood have been afilicted in the same way. Girls are 
much more prone to it than boys, and a child who has once passed 
through an attack is very likely to suffer from it a second time. 

The outbreak of the disorder may be determined by an attack of 
rheumatism, or by some shock to the nervous system, as a fright, or by 
any cause which reduces the strength more or less suddenly and sets up 
anaamia or some cachectic condition. There is an indisputable connection 
between rheumatism and chorea. It is common to find a family history 
of rheumatic attacks. Often the patient has herself suffered from it, either 
in its acute or subacute form. Out of forty-two cases (nine boys and 
thirty-three gills) of whom I have notes, I find distinct history of rheumatic 
attacks in sixteen. Others came of rheumatic families, although it could 
not be discovered that they had suffered from the disease themselves. 
There was a heart-mirrmur in twenty-seven, and in many cases the rheu- 
matic disease had left evident traces of its passage in a harsh cardiac 
murmur with some hypertrophy of the heart. Still, there is no doubt 
that we find many cases of chorea in which no history of rheumatism can 
be discovered, and many rheumatic children never have chorea. Rheuma- 
tism alone will not set up the complaint, for a peculiar instability of the 
nervous system is no doubt essential to the production of the disorder. 
Rilliet states that in Geneva, where rheumatism was a common disease, 
chorea was almost unknown, and according to the investigations of Dr. 
"Weir Mitchell, it appears that amongst negro children, in whom rheu- 
matism is not uncommon, chorea is very rarely seen. 

Dr. Anstie was of opinion that the hereditary rheumatic tendency was 
associated with a hereditary tendency to neurotic diseases of various kinds, 
and especially to chorea. In support of this view he instanced the case 
of nine families with decided rheumatic history. In each of these several 
of the children had suffered from rheumatism, to his own personal 
knowledge. In all of them, also, there was a strong neurotic inheritance, 
which showed itself in many cases in the form of chorea. The striking 
fact consisted in this, that although many children suffered from rheu- 
matism and many from chorea, it was not the victims of rheumatism who 
were especially prone to chorea. As often as not those children who had 



300 DISEASE IN CHILDEEN. 

suffered from rheumatism escaped the neurosis, while others who had 
never had rheumatism fell victims to chorea. 

Other conditions appear to influence the incidence of the disease. The 
rarity of chorea amongst the little negroes seems to show that the degree 
of cerebral development may constitute an important element in the ten- 
dency to the disorder ; for the brain in the black race is no doubt less 
perfectly developed than it is in whites. Again, monotony of life and ab- 
sence of mental excitement must tend to impart immunity from chorea, 
for Dr. Weir Mitchell's researches show that the disease is far less common 
in rural districts than it is in towns, and in small towns than in large cities. 

In a suitable subject any irritant may set up the complaint. Worms 
in the intestinal canal, and, of course, the practice of masturbation, have 
been cited as frequent causes of this as of all other nervous disorders. 
Still, I cannot but think that the influence of the two causes just mentioned, 
of masturbation especially, in provoking nervous derangements in the child 
has been greatly exaggerated. Chorea is sometimes associated with grave 
diseases of the nervous centres. It has been seen in connection with cere- 
bral tubercle, cerebral hypertrophy, and softening of the brain ; and Dr. 
Jacoby has reported a case in which violent choreic movements were in- 
duced by meningitis involving the membranes of the cervical part of the 
spinal cord. 

Pathology. — The pathology of chorea is still a matter of debate. In 
some fatal cases obstructions have been discovered in the minute arteries 
ramifying in the corpus striatum and its vicinity, with little points of soft- 
ening and congestion resulting from them. Hence Dr. Kirke's view, 
since supported by the authority of Dr. Hughlings Jackson, that chorea is 
a consequence of minute emboli swept out of the heart and arrested in the 
small arteries of this part of the brain. This theory, if correct, would only 
explain the cases which have been preceded by rheumatism, and would 
throw no light on the many cases where the heart is to all appearance 
healthy. 

Dr. Dickinson has proposed another explanation. He believes that the 
faulty part of the brain is not limited to so small an area. In his opinion 
the disease depends upon a wide-spread hyperemia of the nervous centres 
"not due to any mechanical mischance, but produced by causes mainly of 
two kinds — one being the rheumatic condition, the other comprising vari- 
ous forms of irritation, mental and reflex, belonging especially to the ner- 
vous system." Dr. Dickinson has found, as the result of post-mortem ex- 
aminations of fatal cases, that all the small arteries both of the brain and 
spinal cord have a general tendency to dilatation. As a consequence, exu- 
dations and sometimes minute haemorrhages occur in the tissues immedi- 
ately surrounding the dilated vessels — shown by the presence of blood- 
crystals and patches of sclerosis. He has noticed these changes to be most 
advanced in the corpora striata, the vicinity of the trunks of the middle 
cerebral arteries, and in the posterior and lateral parts of the spinal cord 
— principally at the upper part ; and states that they are equally distrib- 
uted on the two sides. This theory has the advantage that it explains the 
wasting of muscles, rigidity of limbs, and occasional permanent paralyses 
which sometimes follow an attack of chorea. 

In opposition to the above theories based upon morbid anatomy, Dr. 
Sturges has advanced an ingenious explanation of the phenomena attend- 
ant upon chorea, founded upon intimate acquaintance with the peculiarities 
of childhood. Dr. Sturges regards chorea as a purely functional complaint, 
arising, in the majority of cases, from some strong nervous impression. 



CHOREA — PATHOLOGY — SYMPTOMS. 301 

Starting from the fact that in every child placed in an embarrassing posi- 
tion emotional restlessness (or temporary chorea) is produced, he argues 
that exaggerated limb-movement is the natural expression in young sub- 
jects of emotional states; that disordered movement is increased by the at- 
tention being diverted, as it is by some strong emotional shock ; that the 
consciousness of this partial loss of control deepens the mental impression 
and intensifies and extends its consequences ; and, lastly, that want of suc- 
cess in directing movement impairs the child's confidence and entails fur- 
ther failure. The little treatise is well worthy of perusal, for although it 
may not offer a full explanation of all the phenomena connected with the 
disorder, no one can refuse admiration to the ingenuity of its reasoning 
and the graces of its style. 

Dr. Haydon, of Dublin, has started another theory. Like Dr. Sturges 
he refuses to accept any special organic lesion as the exciting cause of the 
complaint. He believes that the attack begins with a vaso-motor paresis, 
the consequence of a profound emotional impression, and that the essen- 
tial symptoms are due to defective polarity or dynamic instability of the 
motor-nerve tracts, both intracranial and spinal. This hypothesis would 
explain the post-mortem appearances noted by Dr. Dickinson, and would 
account for the phenomena common in the graver cases of the disorder. 

Symptoms. — The phenomena of chorea consist in an inability to guide 
and control the muscles, so that while there is excess of motion there is 
absence of ordered movement. The infirmity begins gradually in most 
cases. At first the child is noticed to be stupid over her lessons ; she 
shows less than her usual alacrity at her games, and is emotional, nervous, 
and altogether strange in manner. Soon she begins to fidget, scraping 
her feet as she sits on a chair, or restlessly moving one of her hands about 
her dress. Then she is found to drop articles from her hand, and to 
stumble awkwardly as she walks. These symptoms are always at first 
attributed to carelessness, and the child is admonished and reproved ; but 
after a time, usually from some eccentricity of movement or facial contor- 
tion, it dawns upon the parents that the child's control over her muscles is 
impaired, and the matter is referred to the medical attendant. 

In exceptional cases the symptoms do not come on in this insidious 
way, but begin with some suddenness as a consequence of fright or other 
shock to the nervous system. But however the disorder may have begun, 
when fully developed the symptoms are the same. The power of the will 
to control muscular action appears to be completely lost, and we find 
spontaneous spasmodic movement, inco-ordination of voluntary movement, 
and a certain degree of muscular weakness. 

In a marked case nearly all the voluntary muscles of the body seem to 
take their share in this disorder of movement. The child is never quiet. 
First one group of muscles, then another, contract in a jerky spasmodic 
manner which is very characteristic. Volition is evidently not concerned 
in their production. They occur not only without the influence of the 
will, but in spite of it. The face is curiously worked, as if the muscles 
were attempting, but unsuccessfully, to simulate all the passions of the 
mind. The eyebrows are suddenly bent into a frown ; but it is not 
anger. The mouth expands abruptly into a smile ; but conveys no im- 
pression of mirth. The eyelids are opened widely ; then quickly squeezed 
together ; the eyes are rolled upwards, downwards, and from side to side ; 
the cheeks twitch, and the angles of the mouth are contorted with strange 
grimaces. The head is jerked backwards and forwards, and then pulled 
suddenly down to one side. The arm may be thrown abruptly forwards 



302 DISEASE IN CHILDREN. 

by a peculiar movement of the shoulder ; the hand and wrist are violently 
pronated, then as suddenly supinated, and the fingers work convulsively. 
Sometimes, by a strong effort of the will, the hand may be kept quiet for 
a few seconds, but soon, with a convulsive jerk, it is thrown again into 
motion. The lower limbs, although less violently affected, are not inac- 
tive. They are thrown one over the other, or are suddenly drawn up and 
again extended. 

Sometimes the muscles of the trunk may be affected, and spasmodic 
contractions of the respiratory muscles may take place ; or the patient 
may be suddenly jerked upwards from the bed, or even thrown out of it 
upon the floor. In the worst cases the child has a wild, frightened look, 
or sometimes a half- dazed expression ; speech may be impossible, and even 
memory may appear to be almost lost. 

In the milder cases an effort to execute a voluntary act increases the 
contractions ; and even the exertion of standing makes control of the 
muscles more difficult. The more completely the child is at rest, the 
quieter she becomes. The movements are also increased by mental emo- 
tion and nervousness, so that the child is always at her worst when 
observed ; and no doubt, as Dr. Sturges suggests, the consciousness of 
failure increases her helplessness. During the height of the complaint 
the ungovernable eccentricity of movement makes the commonest actions 
difficult or impossible ; for an attempt to direct any special group of muscles 
is immediately frustrated by violent contractions of antagonistic groups, so 
that the patient does anything but what she wishes. The child can only 
speak indistinctly ; she cannot button or tie her clothes, or perform any 
act in which accurate co-ordination of movement is required. For this 
reason it is often quite impossible for her to feed herself, as she can no 
longer guide the spoon or fork to her lips. Even when fed by the nurse, 
mastication may be difficult from irregular movements of the tongue ; and 
sometimes the contractions of the gullet are interfered with in the process 
of swallowing. In bad cases natural sleep is almost impossible. Even in 
a milder form of the complaint the child finds a difficulty in going to sleep ; 
but when she does at last sleep the movements cease. 

Sometimes sensory disturbances can be noticed. Painful spots may be 
found in the course of the nerve-trunks in the affected parts ; there may 
be tenderness on pressure over the spinous processes of the vertebrae ; or 
the child may complain of hyperesthesia or anaesthesia of the skin. Occa- 
sionally sight is impaired. 

The choreic movements are not always general ; sometimes they are 
limited to one-half of the body (hemichorea). In these cases either side 
may be attacked ; but even in hemichorea, according to Dr. Broadbent, 
muscles bilaterally associated in their action are affected to some extent on 
the two sides. When the disorder is unilateral, the muscular weakness, 
which is seldom completely absent, is more easy to recognise, as we have 
in the sound side a standard of comparison. When sensation is impaired 
in hemichorea, it is impaired on the same side of the body as that on 
which the muscles are affected. This fact is relied upon by Dr. Broadbent 
as a proof that the seat of the disease is not in the cord ; for if it were so, 
sensation would be impaired on the side opposite to the affected muscles. 

The constant movement seems to cause wonderfully little muscular 
fatigue. In ordinary cases, if the movements are not exceptionally violent 
the general health is but little affected. The child may complain of gid- 
diness and headache, but appetite is usually good, and the digestive 
functions are well performed, although the bowels may be costive. In bad 



CHOREA— SYMPTOMS. 303 

cases appetite is often capricious and digestion impaired, and partly for 
this reason, partly from the difficulty in feeding the patient and the want 
of sleep, nutrition may suffer and the child become pale and thin. 

The urine has always a high specific gravity at the height of the dis- 
ease, and contains abundant urea and phosphates. 

The mental condition may vary, according to the severity of the dis- 
order, from mere depression or irritability to taciturnity, obstinacy, vio- 
lence of disposition, or even furious delirium. In the milder cases intelli- 
gence does not appear to be enfeebled, and although the patient often has 
a silly vacant expression, this is no more than can be accounted for by the 
child's own feeling of helplessness, and her consciousness that her contor- 
tions and grimaces may be the subject of ridicule. 

The temperature in chorea is normal unless the complaint be compli- 
cated with a rheumatic attack, or be symptomatic of organic disease of the 
nervous centres. 

Weakness of the muscles has already been referred to as an essential 
symptom of the disorder, but as a rule it is insignificant, and may not be 
noticed without special inquiry. Sometimes, however, the muscular weak- 
ness assumes great prominence, and may even throw all the other symp- 
toms into the shade. Thus a form of the disease is sometimes met with 
in which a paralysis or paresis of one or more limbs is the only symptom 
complained of. For instance, a little girl is said to have gradually lost the 
use of her arm. The hand hangs down and is evidently very weak. The 
patient may perhaps by a great effort of will be able to raise it, but when 
she tries to grasp with the fingers the pressure is very feeble. The leg of 
the same side is sound, and there is no j)aralysis of the face or tongue. 
Sometimes the other arm is also weak, although to a less degree. In other 
cases the paralysis involves the leg as well as the arm of one side, but the 
face and tongue always escape. In all these cases, although to a casual 
glance there may appear to be no movement at all, careful inspection will 
usually discover occasional slight twitches — faint clonic spasms — in the 
affected limb or on the sound side. Sometimes this is all that can be 
noticed, and the muscular power returns after a time without the occur- 
rence of any confirmed disorder of movement. In other cases the clonic 
spasms become more and more marked as the paresis improves, so that 
when the power of the affected limb is almost restored the motor disorder 
is at its height. 

There is another form of muscular weakness which occurs later, and 
sometimes remains as a permanent condition after the disease has passed 
off. It affects the muscles which have been previously implicated, and is 
probably clue to degenerative changes in the spinal cord. The muscles 
remain weak and become wasted, and perhaps contracted. 

The state of the heart in chorea is very interesting. In a large propor- 
tion of cases, at least of those occurring in young children, a mitral mur- 
mur becomes developed in the course of the illness. This murmur may 
disappear as the symptoms of motor disorder decline, or may remain as a 
permanent condition. The temporary murmurs are often very variable in 
intensity ; coming and going ; heard with some beats of the heart and not 
with others. These are probably due to some irregular action of the 
papillary muscles of the heart, the consequence of clonic spasm similar to 
that which takes place in the .voluntary muscles of the body. Temporary 
murmurs, when not thus interrupted, may be the result of amemia — a 
condition in which the blood is watery and the tissues of the heart relaxed, 
so that the left ventricle is dilated and the mitral orifice is insufficiently 



304 DISEASE IX CHILDREN. 

closed by its valve. In these cases there is often a basic pulmonary mur- 
mur. We cannot say positively that a murmur has disappeared until we 
have examined the chest after exertion as well as when the heart is quiet. 
It is important, therefore, before pronouncing an opinion, to excite the 
heart's action by making the child run round the room. If the heart-sounds 
after this exercise still remain clear, we can say decidedly that the murmur 
has gone. Temporary murmurs are much more common in girls than in 
boys. 

Permanent murmurs are in all cases, probably, the result of endocar- 
ditis, which may be due to coincident rheumatism, or may arise in the 
course of the illness without rheumatic taint. 

The choreic disorder runs a chronic course, but in the large majority 
of cases ends in complete recovery. Its progress is, however, often un- 
equal, and the child may be better and worse again several times before 
control over muscular movement is completely restored. After all in- 
voluntary spasm has subsided, a certain abruptness of executing voluntary 
acts may continue for a time before all traces of the disorder pass away. 
Kelapses after an interval of months or years are very common. 

The duration of chorea varies greatly. If left to itself it lasts from one 
to two months, seldom longer, although cases are recorded in which mus- 
cular disturbance has continued through life. As a rule, the disease can 
be greatly influenced by treatment. When the complaint passes off, recov- 
ery in most cases is complete. Sometimes, however, the mind remains 
more or less enfeebled ; the patient becomes slovenly, careless, and dirty 
in her habits, and may even drift into a state of permanent weakness of 
mind. In other cases the contrary happens, and the intellect seems bright- 
ened by the attack. Sometimes, although fortunately very rarely, some of 
the affected muscles undergo atrophy and contraction. 

Death from the disease is very uncommon in children, but it sometimes 
occurs from the violence of the disease, the patient being worn out by 
want of sleep, insufficient nourishment, and muscular exhaustion. Death 
is usually preceded by delirium and coma. In the bad cases the chafing 
of the skin produced by constant friction becomes a source of great dis- 
comfort, and may induce an attack of fatal erysipelas. 

Diagnosis. — In a well-marked case of chorea the absence of monotony 
and rhythm in the movements, their abruptness and variety, their com- 
plete independence of the will, and their occurrence in spite of all efforts 
to restrain them, make mistake impossible. The cases which begin with 
paresis, and in which the muscular movement is a subordinate and insig- 
nificant feature, are less immediately recognisable. In such cases careful 
observation is often required to ascertain the existence of muscular spasm. 
According to Dr. Gowers, whenever a child of the choreic age suffers from 
gradual loss of power in the arm, and presents no weakness of face, 
tongue, or leg, the disease is invariably chorea. If the nature of the com- 
plaint be suspected, we must look for confirmatory evidence, and slight oc- 
casional spasm will be usually detected in the weak arm or in the sound 
one. 

Prognosis. — The immediate prognosis is almost always favourable, and 
very severe cases in children under twelve years of age seldom do other- 
wise than well. The worst cases are seen in girls who have menstruated, 
and it must be remembered that the catamenia sometimes appears at a 
very early age. 

The influence of the disease upon a child's future life has also to be 
considered. If the patient have strong neurotic tendencies derived from 



CHOREA — TREATMENT. 305 

inheritance, we may feel less sanguine than we otherwise should be as to 
the after-effects of the illness. In such cases much will depend upon the moral 
influences which may be brought to bear upon the child. The form of 
the complaint in which muscular weakness is the prominent and early 
synrptoru, seldom passes into very severe general chorea, but it often 
proves an obstinate ailment and difficult of cure. 

Treatment. — Chorea is a disease which is decidedly influenced by treat- 
ment in the wider sense of the word, as distinguished from mere drug- 
giving. Our first care should be to see that the muscles are spared all un- 
necessary exertion ; and tnat the child is kept as quiet as possible in 
bed. We should then attend to all the bodily functions — see that the 
bowels are regularly relieved ; that any worms present in them are re- 
moved ; that the skin and kidneys act well ; that the diet is regu- 
lated with a proper proportion of animal and vegetable substances ; and 
that the child does not take too much farinaceous matter or sweets. In 
most cases the subjects of chorea are anaemic and weak, with flabby mus- 
cles ; not unfrequently the skin is dry and acts imperfectly. To re- 
store the skin to its natural condition the body should be oiled all over 
at night, and in the morning the child should be thoroughly washed with 
soap and hot water. After a few days the normal softness and suppleness 
of the skin will be restored. A cold douche may be then added to the 
treatment. If the child be not weakly, the douche may be given after her 
ordinary bath as she sits in the warm water. In the case of a weakly 
child it is better to separate the ordinary washing from the invigorating 
douche. The patient may take her usual bath in the evening, and in the 
morning the douche may be given as the child sits in hot water, after 
complete preparation of the skin by vigorous shampooing (see Introduc- 
tion). In this process the shampooing, besides preparing the skin to resist 
the shock of the cold water, seems to have a directly beneficial effect upon 
the muscles. 

Moral treatment is of the utmost importance. The child is, as a rule, 
weakened and demoralised by the new couditions in which she finds her- 
self, and much may be done by kindness, firmness, and vigilant attention 
to her wants to restore the balance of her mind. At first she should be 
amused as much as possible, and endeavours should be made to anticipate 
her wishes, so that she may be spared the constant sense of failure. "When 
the symptoms begin to improve, the child may be allowed to leave her 
bed ; and games which involve rhythmical movement, such as the skipping- 
rope, should be encouraged. Benedikt recommends a weak constant cur- 
rent along the spine. The child should stand up during the application, 
and the current should be just strong enough to be distinctly felt. 

With regard to drugs, the whole pharmacopoeia has been ransacked for 
remedies for this complaint. The disorder has been attacked with anti- 
rheumatic remedies, on account of its connection with rheumatism ; with 
iron, cod-liver oil, and tonics generally, on account of the weakness and 
pallor with which it is usually associated ; with phosphorus and other 
nervine tonics and stimulants, to strengthen the nervous system ; and with 
the whole long list of antispasmodics, sedatives, and narcotics, to reduce 
nervous excitement. Where there is great anaemia iron is very useful, and 
should be always given. In these cases, too, alcohol is of great service, 
and the child should take a wine-glassful of sound claret, diluted with an 
equal quantity of water, with her dinner. Of all the drugs which have 
been recommended as specifics in this complaint the only one from which 
I have ever seen any decided benefit has been arsenic, and with this only 
20 



306 DISEASE IN CHILDREN. 

in large closes. Children bear arsenic well. I have been in the habit of 
prescribing for a child of five or six years of age ten drops of Fowler's 
solution of arsenic, directly after meals, three times a day. In this dose it 
is rarely found to disagree. If the child complain of discomfort at the 
epigastrium, and vomit a short time after taking the remedy — and these 
are the only unpleasant symptoms I have known the medicine to produce — 
it can be given for a time twice a day or in smaller doses. In every case 
the dose should be as large a one as can be borne without discomfort, and 
given thus immediate benefit will usually ensue. In cases where arsenic 
is ill borne by the stomach, or where it has been given without producing 
benefit, the drug may be administered hypodermically. Dr. W. A. 
Hammond, of New York, speaks in high praise of this manner of treating 
the disease, and states that thus administered the remedy can be tolerated 
by the system in doses considerably larger than if it were given by the 
mouth. Dr. Hammond directs that the injection should be made slowly 
at a spot where the skin is loose, such as the front of the forearm ; that 
care should be taken to conduct the fluid into the subcutaneous tissue and 
not into the skin or underlying muscles ; and that Fowler's solution should 
be used diluted with an equal proportion of glycerine. The injection 
should be made once in the twenty-four hours, beginning with ten or 
twelve drops of the solution, and increasing the quantity by one drop each 
day. 

Almost every writer on this subject has his favourite remedy. Trousseau 
advocates the claims of morphia and strychnia ; Sir Thomas Watson speaks 
in high praise of turpentine. Sulphate of zinc is said to be a specific by 
some ; others prefer bromide of potassium or chloral. "Without going 
through the list of drugs specially recommended, it may be sufficient to 
say that it is now generally held that the bromides are most useful in cases 
where the movements are violent and exhausting, especially if there be any 
reason to suspect ovarian excitement ; that zinc should be preferred for 
florid children and the more acute cases, iron for the pallid subjects 
weakened by chronic illness, and that arsenic given by the mouth effects 
its most rapid cures in the simpler forms of the disease where the muscular 
disturbance is not extreme. In cases of acute chorea dependent uj>on 
meningitis or medullary congestion or inflammation, and accompanied by a 
high temperature, Dr. Jacoby recommends the liquid extract of ergot, 
given in half- drachm doses to a child five years of age, three or four times 
a day, and continued for many weeks in succession. 

In very bad cases, where the movements are violent and incessant, where 
the child cannot sleep, and takes food with the utmost difficulty, the best 
plan is to put the patient under chloroform at stated intervals and feed 
her through an elastic catheter passed down the gullet. In such cases a 
sufficient quantity of stimulant should be supplied with each meal. At 
night-time, in order to insure sleep, a full dose of morphia should be given 
hypodermically. Much benefit is sometimes derived from Jaccould's plan 
of spraying with ether the whole length of the spine twice a day. Dr. 
Anstie records the case of a boy, aged six years, w T ho had been reduced by 
the violence of the disease into an almost hopeless condition. At length 
the ether spray w r as begun. The boy at once began to improve, and in a 
fortnight the disease was at an end. 

Obstinate cases of chorea may be sometimes cured by the plan originated 
by Dr. Weir Mitchell and ably practised by Dr. Playfair in cases of 
aggravated hysteria in women. The plan consists in vigorous shampooing 
or "massage" of the muscles, so as to excite excessive muscular waste, and 



CHOREA — TREATMENT. 307 

in supplying the waste so induced by regular and excessive feeding. The 
shampooing must be carried out energetically. It consists in kneading 
the muscles and making passive movements of the joints. This should be 
done several times daily for half an hour on each occasion. At the same 
time the patient is fed with large quantities of milk, meat, eggs, and other 
nourishing food. By this means all the more violent movements are 
quickly controlled, the extremities become warm, the child sleeps soundly 
and rapidly puts on flesh. 

In every case where the movements are violent care should be taken 
that the patient receives no injury from knocking or bruising or chafing 
the skin. The sides of the cot should be padded ; and the child should 
be confined to the bed by a folded sheet passed over the chest and tied 
underneath the cot. 

When the disease has passed off, means must be taken to discipline the 
mind by a judicious system of education, both moral and intellectual, and 
the child should be encouraged to take part in active games and out-of- 
door exercises. A change to the sea-side is often useful to complete the 
cure. 



CHAPTEK VIII. 

IDIOPATHIC TETANUS. 

Tetanus or lock-jaw, as it attacks new-born children, is a disease of which 
in England we know little by actual experience. A few cases are, however, 
seen from time to time, and it is not unlikely that but for the tender age 
of the infant attacked, and the rapidity with which the disease hurries to a 
close, more examples of the malady might come under observation. Cer- 
tainly, at the east end of London, in the Irish quarters, where squalor and 
poverty are often extreme, it is strangely common to hear of several infants 
of a family having died a few days after birth from " convulsions." Such 
cases have probably come under the notice of no more experienced obser- 
ver than an ordinary midwife, and it is quite possible that many cases of 
infantile tetanus may thus escape recognition. 

The disease consists in an intense irritability of the spinal cord and the 
motor nerves which proceed from it, throwing the whole body into violent 
tonic spasms. Infantile tetanus runs a very acute course and generally 
ends in death. It is common in the West Indian islands, in South America, 
and in the southern portion of the United States. In these warm climates 
it attacks by preference the new-born children of the negro population. 
It is also occasionally found in more temperate zones. The island of St. 
Kilcla in the Hebrides has long been notorious for its enormous infant mor- 
tality from this cause, and sometimes in other parts of Europe the disease 
occurs sporadically or even in occasional epidemics. 

Causation. — Much speculation has been bestowed upon the etiology of 
the disease as it occurs in new-born infants, and many theories have been 
devised to account for it. The fact that the symptoms appear within a few 
days of birth seems to point to some traumatic cause for the illness, and 
suspicion naturally fell at once upon the remnant of the newly divided um- 
bilical cord. Hence the disease has been ascribed to phlebitis of the um- 
bilical veins. The explanation has, however, been proved to be erroneous. 
Dr. Mildner, of Prague, has collected forty-six cases of inflammation of the 
umbilical vessels which ended fatally. In only five of these did convulsions 
form part of the symptoms, and in no instance did the convulsions bear 
any resemblance to those characteristic of tetanus. Again, phlebitis of the 
umbilical veins, although an occasional accompaniment of infantile tetanus, 
is more often absent than present. Inflammation, then, cannot be a 
cause of the disease, but still it does not follow that tetanus is independent 
of the condition of the cord. Even in the adult inflammation of a wound 
is not essential to the production of traumatic lockjaw, for the malady has 
been known to occur in cases where the wound had undergone healthy 
cicatrisation. 

Mechanical causes for the disease, such as blows or accidental injuries, 
and the use of too hot water for the bath, have been suggested by some 
authors. An eminent American writer has attributed the disorder to press- 



TETANUS — CAUSATION — MORBID ANATOMY. 309 

ure on the medulla oblongata and its nerves, through displacement oc- 
curring either during labour, or after birth from the child being allowed to 
lie for days together with the back of his head upon a pillow. 

Although the disease may arise from these or other traumatic causes, 
it seems likely that an explanation of the phenomena is to be found in 
general rather than in local agencies. The influence of sudden changes of 
temperature in producing tetanus hardly admits of doubt. In all countries 
where the complaint is prevalent there are rapid alternations of tempera- 
ture, the heat of the day passing suddenly into the cool of the evening. On 
this account interruption to the functions of the skin has been suggested 
as the immediate cause of the disease. In the same way chilling of the 
surface by exposure to cold and wet has been said to be capable of exciting 
the tetanic convulsion. Of all causes, however, to which the disease has 
been attributed foul air generated by filth and imperfect ventilation is, 
perhaps, one of the best established. The often quoted case of the Dublin 
Lying-in-x4.sylum seems to prove this conclusively. Before 1772 nearly one 
in every six of the children born alive in the asylum died, and the cause of 
death was almost invariably tetanus. In that year Dr. Joseph Clarke intro- 
duced a complete system of ventilation into the hospital. The consequence 
was that the mortality immediately fell to one in nineteen. Later, the 
proportion of deaths was still further reduced to one in fifty-eight, and of 
those who died little more than a ninth died from this disease. 

In St. Kilda the high rate of mortality may with much probability be 
attributed to a similar absence of fresh air and cleanliness in their homes. 
That some cause is there in existence which does not obtain in the neigh- 
bouring islands is evident, for children born of natives of St. Kilda out of 
the island escape the disease, and hence the occurrence of the affection can- 
not be attributed to intermarriage or any hereditary influence. 

Dr. Holland in his " Summary of the Diseases of the Icelanders," re- 
cords the frequency of trismus nascentium in the island of Heimaey, one 
of a group situated on the southern coast of Iceland. He states that almost 
every infant born on the island died of this disease, and that consequently 
the population was supported almost entirely by immigration from the 
mainland. It appears that there was no vegetable food upon the island, and 
that the natives lived principally upon sea-birds which they salted and 
barrelled. Dr. Holland attributes the disease to irritation of the bow^els 
excited by the practice of feeding the infants shortly after birth upon a 
strong and oily animal food. He fortifies his opinion by the fact that at 
St. Kilda, where the diet and mode of life of the natives resembled those 
prevailing at Heimaey, the disease was equally prevalent and equally fatal. 

Tetanus is occasionally seen in older children, as a consequence of some 
cut, or bruise, or other injury, as is the case in the adult. Sometimes it 
is idiopathic, and is then probably rheumatic in its nature. 

Morbid Anatomy. — Extreme injection of the small vessels of the spinal 
cord and its membranes, with extravasation of blood into the cellular tis- 
sue around the theca, and also into the cavity of the spinal arachnoid, has 
usually been described as a common consequence of infantile tetanus. In 
a case which died in the East London Children's Hospital, under the care 
of my colleague, Mr. Parker, there was a striking absence of congestion of 
the cord and its membranes. On opening the spinal canal the loose con- 
nective tissue around the cord was found to be ecchymosed in patches 
from the middle to the lower end of the dorsal portion of the cord. On 
opening the spinal dura mater, the pia mater did not present any unusual 
appearance. It did not appear abnormally congested. The cord itself 



310 DISEASE m CHILDREN". 

was firm to the touch. On cutting into it, the gray matter was clearly 
mapped out by its pink colour when compared with the white substance. 
There were no extravasations into its substance at any point. 

In some cases in adults Kokitansky and Demme have observed a de- 
velopment of connective tissue in the spinal cord. 

Symptoms. — The disease generally begins on the third, fourth, or fifth 
day after birth. It is rarely delayed longer than the tenth. The first 
symptom mentioned by the mother is usually that the child cannot take 
the breast, or that if he attempt to do so he quickly abandons the nipple. 
Sometimes the milk is noticed to run out of his mouth, as if he had a diffi- 
culty in swallowing it. Soon the jaws become stiff and the face has a 
rigid, pinched look. The spasms extend from the muscles of the jaw to 
the neck, the back, and finally the limbs, so that in a short time a general 
muscular rigidity is observed, which comes on in paroxysms, lasts for a 
variable time, and then remits to return after a short interval. The infant 
may utter a pitiful whimper when the paroxysm begins, but at once the 
muscles become stiff and hard, the eyes are tightly closed, the jaws are 
set, with the mouth a little open, the head is drawn backwards, the hands 
are clenched, and the feet are flexed upon the ankles. Sometimes there is 
opisthotonos. If the paroxysm is short respiration may be suspended 
and the face become dusky, but in the longer attacks breathing generally 
continues. Each attack lasts from a few seconds to half a minute, and 
the intervals between them may be a few minutes or loDger. In the inter- 
val the spasm does not completely relax, there is some lividity of the face, 
the head often remains more or less retracted, the hands continue clenched 
and the thumbs are twisted inwards. At this time a touch will frequently 
excite the recurrence of the paroxysm. If milk is put into the mouth the 
child may be unable to swallow it, or if he attempt to do so the effort 
may bring on a return of the spasms. The want of nourishment and the 
exhaustion induced by the convulsions cause rapid emaciation. In most 
cases the interval between the attacks becomes shorter and shorter, and 
the child sinks exhausted, or dies asphyxiated from spasm of the muscles 
of respiration. From the very beginning of the attack the child ceases 
entirely to cry. Occasionally he may whimper faintly, but a loud cry is 
never heard. The temperature usually varies from 99.5° to 101° or 102°. 
It may fall below the normal level before death, or may rise to 104° or 
105°. In a case recorded by Ingersley the temperature in some of the 
attacks reached 107°. In this case albumen and casts were found in the 
urine, and the kidneys, after death, showed marks of acute nephritis, with 
extravasations of blood. 

Death usually occurs at the end of a day or two. The infant seldom 
recovers if the paroxysms have appeared before the third day after birth. 
If the child live six days after the appearance of the first symptoms, the 
case may terminate favourably. 

In Mr. Parker's case, before referred to, the arms were noticed to be 
stiff immediately after birth, and they could not be flexed. For a day or 
two the child sucked without difficulty, then the milk was observed to 
run out of his mouth. On the fifth day, soon after the navel-string fell off, 
he began to have slight spasms. If the nipple was put into his mouth the 
spasms were immediately excited. On admission on the fifth day the 
cranial bones presented no abnormality. The child lay with the eyelids 
screwed up. Jdis mouth was not quite closed, but any attempt to open it 
wider brought on a tetanic spasm. There was no risus sardonicus. When 
stripped, the child's body was seen to be covered with hemorrhagic flea- 



TETANUS— SYMPTOMS. 311 

bites. The umbilicus was slightly red and inflamed, but there was no dis- 
charge from it. There were no marks of violence, nor any sores of any 
kind about the body. The limbs were rigid and outstretched, the legs 
rather less so than the arms ; the hands were clenched. The abdominal 
and thoracic walls were also rigid during the spasm, but they partially re- 
laxed after the spasm had passed off. The limbs never quite relaxed dur- 
ing the intervals. The spasms were of short duration (a quarter to half a 
minute), and affected the whole body at once. They recurred very rapidly, 
and the slightest touch sufficed to bring them on. Respiration was quite 
arrested during the paroxysm. There was no opisthotonos. The temper- 
ature, taken in the rectum, was 103.8°. 

The case was treated with the calabar bean extract, of which one-sixth 
of a grain was given every half hour by the mouth ; but as the infant was 
unable to swallow, probably very little of the remedy was really introduced 
into the system. Still, possibly some was absorbed, for after several doses 
the child opened his eyes and was able to swallow milk. He was then 
placed in a warm bath and the bean extract was given every two hours. 
The infant had some spasms during the bath, and a few others shortly 
afterwards, but in the course of an hour they ceased entirely and the 
child seemed to be going on well, when suddenly a violent paroxysm came 
on and he died asphyxiated. The temperature varied, after the first, be- 
tween 100.8° and 102.4°. The child lived only about sixteen hours after 
his admission into the hospital. 

In fatal cases the duration of the illness is usually short. Sometimes 
the infant dies in a few hours, and in the majority of cases all is over be- 
fore the end of the second day. More rarely the child makes a better 
struggle for life, and only succumbs on the eighth or ninth day. When 
the disease takes a mild form from the beginning it may terminate favour- 
ably after a more or less serious illness of two or three weeks. 

When tetanus attacks children after the age of infancy, the symptoms 
are similar to those which are seen in the adult. They are well illustrated 
by the following case of idiopathic tetanus which was under my care in 
the East London Children's Hospital. 

A boy, aged ten years, complained one day on returning from school 
of chilliness, and shivered. For the next three days he seemed poorly and 
complained constantly of feeling cold. On the fourth day, in the evening, 
his neck became stiff, and the stiffness extended to between the shoulders 
so that he held his head backwards. On the following day (the fifth) he 
began to " get straight " from the hips upwards, and the stiffness soon ex- 
tended to the feet. Although very ill, he would sit up in a chair during 
the day, and on one occasion, on being raised to his feet at his own re- 
quest, he became perfectly stiff so that his mother could not bend him or 
replace him in his chair. After about a minute the rigidity subsided and 
he resumed his seat. He complained of no pain except from his tongue, 
which he often bit in these attacks. After this the stiffness returned when- 
ever he moved. His mind was quite clear, but except for asking for what 
he wanted he did not talk. The bowels were much confined. 

The boy was admitted into the hospital on November 12th, two weeks 
after his complaint of chilliness. It was noted that he had no marks of 
external injury. His face was drawn from contraction of the muscles, and 
there was risus sardonicus. Occasionally his body became quite stiff, his 
arms and legs rigid and extended, the abdominal muscles hard and the 
muscles of the nucha contracted. There was no opisthotonos. These at- 
tacks generally came on at night. On the night of November 14th he had 



312 DISEASE IN CHILDREN. 

nine of the spasms, on the 15th, ten. He often bit his tongue. During 
the first few days his pulse was 80 ; temperature, 99-101° ; respiration, 
20-24. The lungs and heart were healthy. 

On the 16th, at 6 p.m., he began to take calabar bean extract, one-sixth 
of a grain every half hour. This reduced his pulse in a few hours to 54. 
On the 17th it was noticed : " Abdominal muscles feel hard, and there is 
much rigidity of the back of the neck. No stiffness of joints of arms or 
legs. Can only partially open mouth, when he does so the muscles under 
the chin become very stiff, but are painless. Keeps his eyes closed although 
light is not distressing to them. Cheeks and eyelids rather red. His face 
has a peculiar drawn expression ; nostrils widely open. Tongue sore from 
biting. Has no difficulty in swallowing. When asleep, the muscles are 
much less rigid than when he is awake, unless during the actual spasm. 
Temperature at 9 a.m., 98.2° ; pulse, 72, small and compressible, regular 
in force but not in rhythm ; respiration, 22." 

During the whole of the 17th the boy had only one paroxysm. In the 
course of the following night he had three attacks. At 10 p.m. on this 
night (the 17th), his pulse being only 48, the medicine was ordered to be 
given every hour instead of half hour. After this the spasms became 
fewer and less severe and the rigidity of the muscles gradually relaxed. 
The spasms still continued to occur at times during sleep, but they usu- 
ally subsided at once when the child was roused. The bean extract was 
stopped on the 25th. His improvement continued and the patient was 
pronounced convalescent on December 12th. The last muscles to become 
completely relaxed were those of the abdominal wall. 

Diagnosis. — Infantile tetanus is a disease which it is not easy to mistake. 
Violent paroxysms of tonic rigidity in which the jaws are set, the chest is 
fixed, the muscles generally are stiff and hard, and the face becomes dusky 
and drawn — these seizures occurring without twitching or sign of clonic 
spasm, and followed by intervals of only partial relaxation, are very char- 
acteristic. 

In older children it is important to distinguish between tetanus and 
the symptoms of strychnia poisoning. According to Sir Robert Christison, 
tetanus does not kill so quickly as a poisonous dose of strychnia. Moreover, 
in tetanus the symptoms become developed gradually ; in strychnia poi- 
soning the convulsions very rapidly become general, and a perfect fit is de- 
veloped in an hour, or even more quickly still. If strychnia have been 
given in carefully graduated doses, the distinction is less easy, but even 
in these cases there are very decided differences. Tetanus begins gradu- 
ally and always runs a continuous course. Sir B. Brcdie declared that he 
had never known a case of tetanus to begin, then subside, and then begin 
again in twenty-four hours. This continuity of symptoms would be diffi- 
cult to simulate even by the most carefully graduated doses of the poison. 
Again, in strychnia poisoning the upper extremities are affected early ; in 
tetanus they are implicated late, and the fingers last of all. The facies, 
too, of tetanus is very peculiar. The forehead is wrinkled perpendicularly 
and transversely, the eyebrows being drawn towards one another in a very 
remarkable manner. The eyes are not fully opened ; there is a "peering 
look " which is very characteristic, and after a time the eyeball becomes 
painfully sunken from tetanic contraction of its muscles. In stiychnia 
poisoning the eyelids are widely opened and the eyeballs protrude. 

Prognosis.-^-So few children recover from this disease that the prog- 
nosis is arways very unfavourable. Dr. Lewis Smith has collected forty 
cases, of which thirty-two died and eight recovered. This is a large pro- 



TETANUS—- DIAGNOSIS — TREATMENT. 313 

portion of recoveries, but statistics gathered from published cases alone 
probably represent but feebly the fatal nature of the illness ; for in so 
mortal a disease it is likely that many more successes than failures would 
be placed upon record. Early occurrence of the symptoms after birth, 
great violence of the spasms, shortness of the period of remission, and 
a very high temperature should excite the gravest apprehensions. The 
most favourable cases are those in which the disease appears after the 
first week has passed. The symptoms are then as a rule less severe, and 
sometimes deglutition is unaffected. The ability or inability of the child 
to swallow is an important element in the case. If he still continue capa- 
ble of swallowing milk from a spoon, we are justified in entertaining some 
hope of ultimate recovery. 

In an. older child the prospect is more favourable if the disease be 
idiopathic than if it follow upon an injury ; but in any case we cannot 
look forward without serious anxiety to the termination of his illness. 

Treatment. — In every case of infantile tetanus our first care should be 
to remove all sources of irritation, whether internal or external. The 
infant must be kept quiet in a room carefully darkened, and the bowels 
should be relieved by a good dose of castor-oil, or if he cannot swallow, by 
a copious enema. Next, the rapid emaciation must be counteracted by 
regular feeding. The great obstacle to efficient nutrition is the spasm of 
the muscles of deglutition which makes swallowing so often impossible. 
Infants cannot be nourished per rectum. It is therefore advisable to put 
the child under chloroform at regular intervals and administer his mother's 
milk, if it can be obtained, or if not, asses' milk, cow's milk and barley- 
water (equal parts), or other suitable food, through an elastic catheter 
passed down the gullet. In this way three or four ounces of food can be 
administered every three hours ; and with each quantity it is advisable to 
mix fifteen or twenty drops of sound brandy. 

The third indication is to control the spasms. For this purpose some 
form of sedative must be resorted to. Opium, alone or combined with 
anti-spasmodics such as sulphate of zinc or assafcetida, Indian hemp, and 
belladonna or its alkaloid have been all employed. Whatever form be 
used, it should be given with the food through the catheter or hypoder- 
mically in frequent small doses. Chloroform checks the paroxysms for a 
time, but they return when the effects of the anaesthetic have passed 
away. Good results have been obtained from the extract of calabar bean. 
In Mr. Parker's case, previously narrated, even the small quantity of the 
remedy absorbed seemed certainly to prolong the intervals of remission, 
although the seizures when they occurred were not diminished in severity. 
The drug should be administered hypodermically if the child cannot swal- 
low. The dose should be one-twelfth of a grain by the mouth, or one- 
twentieth by subcutaneous injection, every hour or two hours, watching 
the effect. It is advisable to produce some decided effect upon the heart 
and lungs, reducing the rapidity of the pulse and the breathing, if any 
good result is to be hoped for. 

Of all the drugs which have been recommended for this disease the 
most favourable results appear to have been obtained from chloral. Dr. 
Widerhofen claims six recoveries in twelve patients by the use of this 
agent, but the only case referred to in the short extract from his lecture 
which appeared in the Lancet, was not of a very severe character, as the 
symptoms came on late and deglutition was not interfered with. In a case 
which was under my care in the East London Children's Hospital this 
remedy was employed, and although the baby died the effect of the drug 



314 DISEASE IN CHILDREN. 

upon the spasms was decidedly encouraging. The difficulty appears to be 
to regulate the dose accurately so as to dominate the seizures without pro- 
ducing too serious a depressioD. For the notes of the case I am indebted 
to Mr. J. Scott Battams the Eesident Medical Officer, who watched the 
child with great attention. 

A little boy, four days old, of healthy Irish parentage, was admitted 
October 18, 1881. The father and mother with three other children be- 
sides the patient occupied one room, which was said to be clean and large. 
The bed in which the child lay with his mother was placed in a strong 
draught, of which the woman had constantly complained. The child was 
born to all appearance healthy, and took the breast well until the day be- 
fore admission, when he w T as noticed for the first time to be unable to 
suck. That night the infant slept badly, crying and drawing up his legs. 
The cry was, however, strong even on the morning of admission. 

When first seen (October 18th, noon) the baby was dirty but seemed well 
nourished ; navel apparently healthy ; cranial bones normal. Every five 
minutes spasms occurred of moderate severity ; they did not arrest the 
breathing. In the spasms the legs were drawn up rigidly, the forearms 
were flexed, the fingers were stretched out and widely separated, the lips 
pouted a little and there was risus sardonicus, the jaw was fixed and the 
head was slightly retracted. An attempt to open the eyes or mouth aggra- 
vated the spasms. At this time the person who brought the child refused 
to leave him without the consent of the mother. At 6 p.m., however, he 
was brought back and admitted. He had taken no food since 11 p.m. of 
the previous evening. The spasms had continued all the afternoon and 
were more severe than at first. The bowels were relieved by enema of a 
large quantity of curd, and the child was put into bed with an ice-bag to the 
spine. Between 7 p.m. and midnight three enemata of milk, containing, 
respectively, four grains, six grains, and six grains of chloral, were admin- 
istered. After three hours the ice-bag was removed. At midnight the 
child was no better. As he remained unable to swallow, he was put under 
chloroform, and three ounces of his mother's milk with four grains of 
chloral were injected through a catheter passed into the stomach. This 
was repeated at 4.30 a.m., after which the catheter was passed without dif- 
ficulty and without chloroform, and between two and three ounces of his 
mother's milk with ten drops of brandy were given every two or three 
hours. During this time the convulsions had varied in intensity as well as 
in number. They were manifestly influenced by the chloral, so that from 
5 a.m. (19th) until 10 a.m. he slept quietly. 

At 10 a.m. (October 19th) the limbs were quite relaxed, and the child's 
face was somewhat dusky. Very little air seemed to be entering the lungs. 
On passing the catheter into the stomach very little spasm was excited. 

At 2 p.m. Mr. Battams was sent for, as the infant was thought to be dead. 
On making artificial respiratory movements the child gave a gasp. From 
this time until 5 p.m. he continued to breathe eight times per minute. 
The conjunctiva? were insensible, the surface was cold, but there was less 
cyanosis. Some brandy was administered. At 10 p.m. his condition remained 
unaltered, except that the respirations were now reduced to four per min- 
ute. No more spasms had occurred. 

On October 20th, at 2.30 a.m., the child was again thought to be dead, 
but artificial respiration revived him for a time ; he, however, finally sank 
about 3 a.m. 

The temperature was 98° on admission (October 18th), 99° at 9 p.m. 
On the 19th it was 100.6° at midnight, 99.8° at 2.15 p.m., 94.8° at 5.30 



TETANUS— TKEATMENT. 315 

p.m., 95.8° at 7.30 p.m., and 96° at 10.30 p.m. No post-mortem examination 
was allowed. 

In this case the remedy was, no donbt, administered too energetically. 
It would have been better, after the first dose or two of the chloral, to 
have given the drug in smaller quantities, even if it had to be repeated 
more frequently. Had this been done, the result might have been differ- 
ent. I have been unable to find any rule by which the administration of 
the remedy may be regulated. Whether it be advisable to proceed to 
actual narcotism, or whether it is preferable to stop short of that point, 
must be a matter for individual experience to acquire, and in this country 
such experience is difficult or impossible to obtain. Widerhofen directs 
gr. j.-ij. by the mouth, or gr. ij.-iv. by the rectum, to be given " at the time 
of each onset of convulsion." This direction is too vague to be useful as 
a guide in practice, and can scarcely be intended to apply to a case such 
as the present, where the intervals of remission were so brief. 

Tobacco and woorara have also been recommended, but must be very 
dangerous drugs to use at so early an age, even when, as in this disease, 
there is such a remarkable tolerance of sedatives. External applications 
are sometimes employed. Warm baths and cold packing have both their 
advocates. In Mr. Parker's case the warm bath seemed to have a decidedly 
unfavourable effect upon the infant. 



CHAPTER IX. 

CONGESTION OF THE BRAIN. 

Congestion of the brain is a term which is often used very loosely, and is 
probably applied to various forms of illness. Writers who have dealt 
with the subject of disease in early life differ curiously in the importance 
they attach to the subject of cerebral hyperemia, some attributing to it 
most of the convulsive diseases to which young children are liable ; others, 
as Valleix, asserting that this pathological condition is almost unknown in 
infancy. 

The view formerly held that the quantity of blood circulating within 
the cranium is constant and cannot be influenced by altered conditions of 
the body generally, has now been proved to be erroneous. The researches 
of Robin and of His have shown that surrounding the cerebral blood-ves- 
sels are lymphatic sheaths which communicate with the lymphatics of the 
pia mater, and are several times the size of the blood-vessels they enclose. 
These lymphatic canals contain a fluid which increases or diminishes in 
quantity according to the varying distention of the blood-vessels, and 
must therefore aliow of great variety in the amount of fluid circulating 
within the cranial cavity. There is no doubt, therefore, that hyperemia 
of the blood-vessels can take place ; but it does not follow because evi- 
dences of this congestion are discovered in the dead body that it was the 
cause of the symptoms from which the patient had suffered. It is common 
in cases of death from convulsions to find engorgement of the vessels of 
the brain and membranes, but this engorgement is probably as often a 
consequence of the convulsion as a cause of it. Still, every physician 
practising amongst children must now and again meet with cases in which 
he finds a group of symptoms suggestive of some temporary increase of 
pressure upon the brain. These symptoms either pass off after a time and 
the child recovers, or they increase, the patient dies, and on examination 
of the skull cavity nothing but a hypersemic state of the cerebral vessels 
with an effusion of serum is seen to account for the illness. These symp- 
toms are therefore supposed to indicate congestion of the brain ; but there 
is probably some deeper and less obvious cause of the impairment of 
function, for although this pathological condition may be invariably pres- 
ent, it cannot be held to furnish a full and satisfactory explanation of the 
phenomena. 

Causation. — Cerebral congestion may occur in two forms : An active 
hyperemia from increased flow of blood into the brain, and a passive hy- 
peremia from obstruction to the return of blood from the interior of the 
skull. Many different causes have been enumerated as giving rise to the 
condition, but it is difficult to accept all of them as determining agents in 
the production of cerebral congestion. Dentition is usually said to be a 
cause of vascular engorgement, because the teething process is often ac- 
companied by convulsive seizures ; but in these cases, if cerebral hyperse- 



CONGESTION OF THE BKAIN — MORBID ANATOMY. 317 

mia occur, it is as likely that the convulsive seizures are the cause of the 
congestion as that the congestion determines the fits. The intense con- 
gestion of the face, and the swelling of the veins of the neck, which are 
always present in a convulsive fit, show that there is impediment to the 
return of blood from the head ; at the same time the heart's action is ex- 
cited, and blood is being propelled rapidly into the cranium. There must 
be therefore great engorgement of the vessels in this region, and if the 
fits are frequently repeated and the child remains for hours, as often hap- 
pens, in a more or less convulsed state, the engorged vessels must relieve 
themselves by effusion of serum, and perhaps by minute haemorrhages. 
Pressure upon the brain set up by this means is sufficient to account for 
the stupor, squinting, etc., which are often found to follow a convulsive 
seizure ; but the effusions are in all probability like the venous congestion 
itself, a consequence rather than a cause of the nervous commotion. 

Even in cases where the cerebral congestion has preceded the convul- 
sion, it seems probable that something besides mere distention of ves- 
sels, unless this be extreme, is necessary to give rise to the eclamptic 
seizure. Some time ago I was asked to see a little child, aged six months, 
who had impetigo of the head. The cervical glands of both sides were 
enlarged and had set up considerable pressure upon the veins of the neck 
— enough, indeed, to induce great oedema of the head and face. In this 
case, where there must have been serious impediment to the return of 
blood from the brain, there were no signs of nervous disturbance. So in 
cases of enlarged bronchial glands with pressure upon the vascular trunks 
in the chest, oedema of the head and neck is sometimes produced, and 
some heaviness may be complained of ; but convulsions are not a symptom 
of the disease. 

It appears probable that in many cases, in addition to the engorged 
state of the blood-vessels, small embolisms or thromboses in the minute 
arteries and capillaries of the brain may be agents in the production of 
nervous symptoms. Dr. Bastian found this condition of the brain in per- 
sons who had died whilst suffering from delirium and coma in the course 
of acute specific diseases, and has recorded his belief that minute and 
widespread congestions are often a consequence of these obstructions. 
There is no reason to suppose that young children differ in this respect 
from older persons ; and probably the convulsive seizures which often oc- 
cur towards the close of measles, scarlatina, and other infectious fevers, 
may owe their origin not to the accompanying congestion, but to minute 
plugging of the cerebral capillaries. Such vascular obliterations, if widely 
distributed, must produce, as Dr. Bastian remarks, " total disturbance in 
the incidence of blood-pressure, and in the conditions of nutritive supply 
in the convolutional gray matter of the brain." 

Besides the eruptive fevers and convulsive attacks, exposure to extreme 
heat and cold, or direct violence applied to the head, may be, directly or 
indirectly, determining causes of acute hypersemia of the brain. A passive 
congestion may be induced in the child during a difficult labour ; it is 
sometimes the consequence of energetic expiratory effort in whooping- 
cough ; it may be set up by diseases of the heart and lungs, or by other 
causes which interfere with the return of blood from the head ; and it may 
be induced by the pressure of intracranial growths upon the cerebral 
sinuses and veins. 

Morbid Anatomy. — A congested brain has a swollen appearance. The 
dura mater is tightly stretched, and if slits are inadvertently made in the 
membrane in the process of removal of the calvarium, the organ bulges 



318 DISEASE IN CHILDREN. 

through the artificial opening. The convolutions look broad. They are 
flattened by pressure against the bones of the skull, and their sulci are nar- 
rowed. The veins of the pia mater are engorged, tortuous, or even vari- 
cose ; and the small vessels are filled to their minute ramifications. The 
cranial sinuses are distended with thick, dark, partially coagulated blood, 
and the choroid plexuses are also congested. The gray matter of the brain 
is also darker than natural, and its section shows fine dots from the in- 
jected vessels. The white substance also contains numerous red points, 
and sometimes the 'cerebral tissue is oedematous, with excess of fluid in 
the ventricles. In cases where the congestion has existed for some time, 
little masses of blood pigment may be found lying outside the vessels 
within the lymphatic sheath. These are described by Bastian as molecular 
grains of a dark olive or amber colour. 

Symptoms. — Signs of general irritability of the nervous system, such 
as heat of head, fretfulness, dislike to light and noise, disturbed sleep, 
startings and twitchings, have been said to constitute an early stage of cere- 
bral congestion. Such symptoms in impressionable infants frequently ac- 
company digestive disturbance and teething, but are more probably due 
to reflex irritation of the nervous centres than to engorgement of the cere- 
bral capillaries and veins. They are often, perhaps, accompanied by in- 
creased activity of the cerebral circulation, but are not necessarily induced 
by it. The so-called " irritative stage " of cerebral congestion, then ap- 
pears to me to be one which cannot be clinically recognised, at least I 
know of no evidence to show that the symptoms said to be characteristic 
of this stage have any necessary relation to an engorged state of the cere- 
bral circulation. 

The common form in which congestion of the brain is met with in 
practice is that in which an infant who has been taken with violent convul- 
sions from teething, or other form of reflex irritation, is left drowsy and 
stupid after the fits have subsided. Instead of clearing quickly away the 
heaviness continues. The child lies with his head retracted on his 
shoulders, sometimes he vomits, and he may even squint. In these cases 
congestion with effusion of serosity into the lateral, ventricles, and perhaps 
the substance of the brain, appears to be an important agent in the pro- 
duction of the symptoms. In cases of death we find excess of fluid in 
the ventricles ; the volume of the brain, is increased, the convolutions are 
flattened, and the vessels of the brain and the pia mater are engorged with 
blood. Such a case has already been narrated in the chapter on convul- 
sions. Another, which seems to have been of a similar kind, although it 
ended differently, is the following : 

A little boy, seven months old, a strong, healthy-looking child, who 
was being brought up at the breast, and had cut four of his teeth, was 
suddenly attacked with vomiting and purging. The symptoms appear 
to have been severe, for after a few hours the child fell into a lethargic 
state in which he lay for four days. At the end of this time he had 
a fit which lasted six hours. For the next ten days he was drowsy and 
half stupefied. His bowels were confined and once or twice he vom- 
ited. 

When I saw the child, on April 8th, he was lying in his mother's arms 
with his eyes half closed. His face was very pale, the pupils were equal, 
dilated, and immovable ; there was no squint ; the fontanelle was very ele- 
vated and tense ; the head was retracted and the muscles at the back of 
the neck felt rigid. The temperature in the rectum was 99°, the pulse and 
respiration could not be counted for irregularity. The lungs and heart 



CONGESTION OF THE BRAIN — SYMPTOMS — DIAGNOSIS. 319 

were healthy. The child took the breast well, and sucked vigorously but 
by snatches. 

He remained in this state, vomiting occasionally, until April 12th, when 
the sickness ceased and the patient seemed very much better. When seen 
on the 15th he appeared to be quite sensible. The pupils were dilated 
and acted imperfectly with light, i.e., when the eyelids were suddenly 
opened the pupils could not be seen to contract. The fontanelle was now 
rather depressed. Pulse, 168, very weak but regular. Skin cool. Head 
not retracted. After this the child soon became quite well, except that 
for some time afterwards he had a peculiar stare, the eyes being directed 
downwards, so as to show a rim of white above the cornea. 

It is difficult to say to what these symptoms were due if congestion of 
the brain and effusion of fluid induced by the convulsion were not the 
cause of them. The normal temperature seemed to exclude any inflamma- 
tory condition ; while the somnolence, the immobility of pupils, the 
swollen and tense state of the fontanelle, and the retracted head pointed 
to some increase of pressure within the skull cavity. If we assume, on the 
strength of Dr. Bastian's observations, that the congestion is the conse- 
quence of wide-spread minute emboli obstructing the circulation through 
the brain, the frequent occurrence of symptoms such as the above is less 
difficult to account for. 

Cases have been recorded and attributed to cerebral congestion in 
which loss of consciousness, with pyrexia, squinting, and general paralysis 
occurred, and passed off completely after a few days or hours. It is diffi- 
cult to understand how a simple local congestion alone can give rise to 
elevation of temperature even in a young child. Such cases are obscure, 
and no sufficient explanation of them has yet been arrived at. 

Many cases of so-called congestion of the brain are probably the con- 
sequence of thrombosis of the cerebral sinuses. Dr. Lewis Smith has 
shown this to be sometimes the case in pertussis ; and convulsions due to 
other causes may be accompanied by similar obstructions to the venous 
passages within the skull. Exact observations upon this point are to be de- 
sired ; but it is probable that increased knowledge will in course of time 
greatly diminish the importance of mere fulness of cerebral veins as an 
agent in the production of nervous disturbance. 

Diagnosis. — When we see a child who is suffering from symptoms indi- 
cative of oppression of the brain, such as drowsiness, immobility of pupils, 
an elevated tense fontanelle, and a retracted head, we have to distinguish 
the case from one of meningitis or other serious cerebral disease. The 
history is here of the utmost importance. If the symptoms began with a 
convulsive attack preceded merely by signs of irritability of the nervous 
system, such as usually usher in a fit of eclampsia ; if the child be the sub- 
ject of rickets, and if some cause such as swollen inflamed gums, otalgia, 
or digestive derangement, can be discovered to account for the nervous 
seizure, we may consider the symptoms to be due to filling of the cerebral 
vessels and effusion of serum into the cranial cavity. If the temperature 
be low, it is a confirmation of this diagnosis. Often, however, in these 
cases the heat of the body is increased as a consequence of the cause which 
has provoked the convulsion. Therefore a high temperature is not neces- 
sarily to be interpreted as casting any doubt upon the accuracy of this 
opinion. In simple meningitis, which begins with violent convulsions 
followed by drowsiness and stupor, there is often a history of chronic 
otorrhcea ; and in most cases the convulsion has been preceded by signs 
of pain in the head. But besides the history, the symptoms in the two 



320 DISEASE IN CHILDREN". 

diseases differ in important particulars. In meningitis the child is at 
once seen to be seriously ill. He refuses his food, and is restless ; he con- 
tracts his brows, raises his hand to his head, rolls his head from side to 
side, and, although heavy and stupid, manifests every sign of suffering. 
The temperature is high, but the pulse is comparatively slow (70-80). 
The fits continually recur, leaving the child more and more stupid and 
comatose. The pupils become unequal, rigidity of the joints comes on, 
and the child dies. 

In cases of congestion and effusion upon the brain the child, although 
heavy and stupid, is quiet and shows no distress. Usually he takes his 
bottle well, and this is an important sign. The fits are rarely repeated 
after the drowsiness has become marked. The pupils, although sluggish, 
are not unequal in size ; and although the head may be retracted there is 
no rigidity of the joints. 

Tubercular meningitis sometimes, although rarely, begins with a con- 
vulsion ; but unless the cerebral symptoms occur as a terminal phase of 
acute general tuberculosis, the disease afterwards runs its normal course, 
which is very unlike that of cerebral congestion. It must be remembered, 
however, that a primary tubercular meningitis is a rarity under the age of 
two years, while the cases of cerebral congestion we have been considering 
are almost limited to the first two years of life. The difference of age is 
therefore an important element in the diagnosis. Still, apart from other 
considerations, congestion of the brain may be usually recognised by re- 
marking that although clrow T sy and stupid the child is not actually uncon- 
scious ; that he continues to take his bottle well ; that his pupils are never 
unequal ; that there is no rigidity of joints, and that loss of powder, although 
it may occur as a consequence of violent convulsions, passes off in a few 
hours unless there be some cause for it more serious than mere exhaustion 
of nervous force. The occurrence of squint lasting more than a few 
hours is very suspicious of a small haemorrhage. It occurred, however, in 
the case narrated in another chapter (see Convulsions), without anything 
being discovered in the brain beyond congestion of vessels and effusion of 
serum. 

Prognosis. — There is always reason for great anxiety when a young 
child shows signs of abnormal heaviness and drowsiness. The mistake 
must not, however, be made of attributing to centric disease natural sleepi- 
ness due to disturbed rest from digestive derangement. It happened to 
me once to be summoned some distance into the country to see a child of 
a few weeks old who was said to have congestion of the brain because it 
was always falling asleep. I found that the child's bowels were disordered, 
and that it was evidently tortured by frequent griping pains. Every few 
minutes it drew its legs up, bent itself backwards, and uttered a feeble 
cry. After some seconds its features relaxed, its eyes closed, and it 
seemed to sleep, but almost immediately afterwards it was aroused by a 
fresh attack of pain. This state of things had continued for forty-eight 
hours. During all that time the child had been prevented from obtaining 
natural sleep owing to the abdominal pains which roused it almost as soon 
as its eyes were closed. After a good dose of castor-oil, which relieved its 
bowels of the irritating matter, the child enjoyed a refreshing sleep and 
awoke quite well. 

The majority of cases of stupor following convulsions recover ; but we 
should be careful not to commit ourselves to a too hopeful prognosis un- 
less improvement begin early and go on apace. As long as the child con- 
tinues to take his food well the prognosis is favourable. If he refuse 



CONGESTION OF THE BRAIN — PROGNOSIS — TREATMENT. 321 

his food, if the drowsiness deepen, the pupils become unequal, or squinting 
occur, the child will probably die. 

When drowsiness is noticed in children as a result of impediment to 
the return of blood from the head, the prognosis is determined ~by the na- 
ture and severity of the disease which has given rise to the passive conges- 
tion. 

Treatment. — "When called to a child who has been left heavy and stupid 
by an attack of convulsions, and we have reason to fear an effusion of fluid 
into the skull cavity, our first care should be to clear out the alimentary 
canal by a dose of calomel and jalapine. We should afterwards keep up a 
free action of the bowels by frequent doses of any suitable saline aperient. 
The child should be kept perfectly quiet in a large well ventilated room 
carefully shaded from a too strong light. If he be at the breast, no other 
food should be allowed. If he be brought up by hand, milk and barley 
water should be given, and but little farinaceous food. If the gums are 
tense and swollen, they may be lanced ; but uuless actual irritation arise 
from this cause the operation is better avoided. If thought desirable cold 
may be applied to the head. In some cases counter -irritation with mustard 
poultices to the chest and spine has seemed to be of service. 

In passive congestion the treatment is that of the disease which has 
given rise to the hyperemia. 
21 



CHAPTER X. 

CEREBRAL HAEMORRHAGE. 

Euptuee of vessels and effusion of blood into the brain is in the child a 
comparatively rare accident. In new-born babies, however, extravasation 
into the arachnoid sac (meningeal haemorrhage) is not uncommon if the 
labour has been difficult and slow. Indeed, Cruveilhier has stated that 
amongst still-born children one-third of the deaths may be attributed to 
this cause. Under three years of age it is rare to meet with any other 
form of intracranial haemorrhage than that into the arachnoid, or the 
meshes of the pia mater, although Billiard found a clot in the left corpus 
striatum in an infant only three days old, and B6rard found a similar 
lesion in a child of eight months. But after the third year a true cerebral 
haemorrhage is more likely to occur, and sometimes it produces much the 
same symptoms as are found in the adult to accompany a clot in the brain. 

Causation. — "When meningeal haemorrhage occurs during birth it is in 
cases where the head of the foetus is locked in the brim of the pelvis, and 
the bones of the skull are forced to overlap from the pressure brought to 
bear upon them. If it occur after the birth of the child it is usually a 
secondary affection, and may be induced by any cause which is capable of 
giving rise to severe and long-continued congestion of the brain. Thus 
it may be found in cases of thrombosis of the cranial sinuses ; it may be 
induced by tumours of the brain pressing upon the torcular Herophili and 
the veins of Galen ; it may be a consequence of convulsions or whooping- 
cough, and it is said to be often found in cases of death from infantile 
tetanus. It appears to be predisposed to by conditions which lead to de- 
bility and cachexia, such as bad feeding and acute exhausting disease. 

The same agencies which induce cerebral haemorrhage in infants may 
cause extravasations of blood into the skull cavity of older children. In 
these subjects the haemorrhage may take place into the meninges, the ven- 
tricles, or the substance of the brain. In haemorrhagic purpura the menin- 
ges of the brain, like other parts of the body, are occasionally the seat of 
extravasations of blood. In many cases, especially when the effusion occurs 
between the dura mater and the skull, the haemorrhage may be attributed 
to a traumatic cause. Children, too, like adults, may die from that com- 
paratively rare accident — rupture of an aneurism on the brain. Cerebral 
aneurism occurs in early life much more frequently than the ordinary 
forms of aneurism. Out of seventy-nine cases collected by Dr. Peacock no 
less than four were found in children between the ages of thirteen and fif- 
teen years, and a boy, twelve years of age, recently died of this disease in 
the Victoria Park Hospital, under the care of one of my colleagues. Still, 
liable as children are to cerebral disease, haemorrhage into or on the brain 
is not common in young subjects, so far at least as can be judged from the 
results of post-mortem examinations. 

Morbid Anatomy. — In young subjects haemorrhage is in general capil- 



CEREBRAL HAEMORRHAGE — MORBID ANATOMY. 323 

lary. Kupture occurs in small vessels and the effusion of blood is gradual. 
In the meninges of the brain the extravasation usually takes place in the 
arachnoid sac ; but it may be also formed between the dura mater and the 
bone, in the meshes of the pia mater, and in the lateral ventricles. In 
the arachnoid sac the blood is either liquid, of the consistence of syrup, 
or is separated into a solid and a liquid portion. On opening the cranium 
the dura mater is of a deep violet colour from the presence of the dark 
clot beneath it. On examination this clot is seen to be spread over the 
surface of the brain. It usually occupies the situation of the posterior lobes 
and the cerebellum, and may even reach as far as the vertebral canal. It 
is thickest in the centre unless a part of it covers the fissure between the 
hemispheres, in which case it is usually thickest at this spot, as it here 
dips down towards the fornix. Towards the circumference it thins off, 
and is usually continued for some distance as a false membrane which re- 
sults from absorption of the colouring matter of the effused blood. This 
false membrane near the clot is readily distinguishable, but it fades grad- 
ually towards the edges and is lost on the surface of the arachnoid. The 
clot generally adheres slightly to the parietal layer of the arachnoid, al- 
though it may be readily separated, and the membrane beneath it, has a 
perfectly normal appearance. The visceral layer of the arachnoid, however, 
is often thickened and opaque. The clot and resulting false membrane 
are in rare cases stratified — an appearance probably produced by succes- 
sive additions to the original extravasation. Sometimes we find more than 
one clot, the effusion having taken place at various points. The thickness 
may be from a few lines to an inch or more. 

A certain amount of fluid, more or less coloured, bathes the surface of 
the clot ; and if the child live long enough the liquid may become enclosed 
in a species of cyst formed by more or less complete adhesion of the edges 
of the false membrane to the surface of the arachnoid covering. Some- 
times the cyst is loculated, and the contents may increase in quantity by 
subsequent secretion. In a case reported by MM. Killiet and Barthez a 
double cyst was found, each chamber containing more than half a litre of 
fluid. When the collection of fluid is thus considerable, it presses out- 
wards the fontanelle and the bones of the skull so as to form a real hydro- 
cephalus. 

It is rare to find haemorrhage in the ventricles ; but it may occur either 
in the walls of the lateral ventricles or into their cavities. Haemorrhage 
into the substance of the brain is also an uncommon lesion, although it 
may occur in infants and children of any age. It is seldom copious. Usu- 
ally when it takes place it is in the course of some other form of illness, 
and perhaps on this account often escapes recognition during life. The 
blood is seen in minute points scattered about the cerebral tissue, or may 
be found collected in little cavities in the brain-substance. These two 
forms are about equally common. The larger collections of blood vary in 
size from a pea to a walnut. Around them the brain-tissue is normal, or 
tinted with rose colour, or slightly softened. The haemorrhages may be 
found at any part of the brain-substance, but are much less common in 
the cerebellum than in the cerebrum. Besides haemorrhages we often find 
in these cases much congestion of the brain ; and there may be also other 
lesions, such as meningitis and even tubercles of the brain, as in a case to 
be afterwards referred to. 

Cases of aneurism of a cerebral artery in young subjects are almost in- 
variably associated with endocarditis, and it is generally held that the ar- 
terial dilatation is the consequence of embolism. It is probable, also, that 



324 , DISEASE ITS CHILDEEN. 

cerebral haemorrhage in the child is more often the result of aneurism than 
is commonly supposed, for this may be easily overlooked. As Sir William 
Gull has observed, "when death takes place from changes around the 
aneurism, as by pressure or softening, the sac itself may present such ap- 
pearances that unless a minute dissection be made of it, its true nature 
may not be discovered." The mechanism by which the aneurismal dilata- 
tion is produced is doubtful. Dr. Ogle attributed it to the impaction of 
the fibrinous clot, and supposed that this afterwards softened and involved 
the coat of the vessel in the process. Dr. Goodhart has suggested that in 
many cases the clot is given off from a valve the seat of ulcerative endo- 
carditis, that this poisons the part where it lodges and "leads to acute 
softening of the arterial wall by inoculating it with its own inflammatory 
action." This explanation is not, however, of universal applicability. 

Symptoms. — The symptoms of meningeal hcemorrhage are unfortunately 
far from being characteristic of the lesion to which they are owing. This 
form of intracranial haemorrhage, indeed, may give rise to no symptoms at 
all. According to M. Parrot, in infants reduced by long-continued bad 
feeding to a cachectic state meningeal haemorrhage is not unfrequently 
found, although during life nothing unusual in the condition of the child 
had been noticed to excite a suspicion of this serious complication. On 
the other hand, in new-born babies extravasation of blood into the arach- 
noid sac may be accompanied by violent convulsions and end in death 
within a few hours. Such a case is recorded by Valleix. A well-developed, 
healthy-looking male infant received a violent bruise on the shoulder two 
days after birth. He seemed to be going on favourably when, on the 
sixth day, he was seized with strong convulsions, which were repeated with 
violence, and in three hours the child was dead. On examination of the 
body a large clot was found in the arachnoid sac ; the veins of the pia ma- 
ter were swollen with blood ; the substance of the brain was injected ; and 
the superior longitudinal sinus was filled with a whitish, semi-transparent, 
gelatinous thrombus. In this case the convulsions must not be attributed 
entirely to the haemorrhage. No doubt the thrombosis had a great share 
in the production of the symptoms, and it was apparently the cause of 
the extravasation. Convulsions are, however, a common consequence of 
arachnoid haemorrhage and repeatedly recur. 

Legendre has described a febrile form of meningeal haemorrhage in 
which the disease begins with vomiting and pyrexia. Convulsive seizures 
soon come on, limited at first to the ocular muscles and giving rise to a 
slight squint. The child sucks well, probably from thirst, and his bowels 
are in a normal state. Soon contractions are noticed of the fingers and 
toes, and general convulsions follow, both tonic and clonic, during which 
consciousness is lost and the face becomes of a dusky red tint. For a time 
the convulsions are comparatively infrequent, and in the intervals the child 
is heavy and drowsy. After a few days the heaviness deepens into stupor, 
the intervals between the fits become shorter and shorter, and towards the 
end of the illness the infant is almost constantly convulsed. The fever 
persists throughout, and death is often hastened by an intercurrent in- 
flammatory complication of the lungs.. 

The above is generally accepted as representing the ordinary course of 
an attack of meningeal haemorrhage in the young child ; but if it induces 
us to look for elevation of temperature as an essential part of the illness 
it is certainly misleading. Statements with regard to temperature, made 
in days before the thermometer came into use as an aid to clinical in- 
vestigation, should be accepted with caution. Moreover, in each of the two 



CEREBRAL HAEMORRHAGE — SYMPTOMS. 325 

illustrations appended by the author to his description of the disease, a 
double catarrhal pneumonia was found to occupy the lungs ; and this 
complication would amply explain any elevation of temperature which 
might have been noticed during life. In cases of intracranial haemorrhage 
unaccompanied by an inflammatory condition of other organs the temper- 
ature, as is shown by a case narrated later, is not raised above the normal 
level. 

The chief difficulty in assigning to this form of haemorrhage its dis- 
tinctive symptoms arises from the fact that it is rare to find a case in 
which the haemorrhage was not secondary to, or complicated by, some 
other malady. Even in instances where no morbid condition of other 
organs is to be discovered it is an open question whether the convulsions 
which are invariably present in such cases give rise to the haemorrhage or the 
haemorrhage to the convulsions. It is worthy of remark that paralysis is 
seldom a consequence of meningeal haemorrhage. The symptoms, indeed, 
are very much those of meningitis affecting the convexity of the brain, 
with the important exception that in cases of haemorrhage there is no 
pyrexia. They also differ from them in the fact that there are no signs of 
headache, and that at first the stupor is not profound. Infants with ex- 
travasation of blood into the meninges, according to the testimony of all 
published cases, take the bottle well for a time. This is no doubt owing 
to thirst rather than to any appetite for food. Still, the fact remains that 
while in arachnoid haemorrhage the child takes food with avidity, in simple 
meningitis of the convexity of the brain he makes little attempt to suck, 
and generally refuses the bottle altogether. 

Haemorrhage into the meninges or on to the surface of the brain is not 
confined to infants. A little girl, aged eight years, was a patient in the 
Victoria Park Chest Hospital, for heart disease and dropsy. The heart 
was enlarged in all directions ; presystolic and systolic murmurs were 
heard at the apex ; there was much oedema of the lower extremities, and 
the urine contained one-third of albumen. The child was kept in bed and 
made considerable progress for about a fortnight, when some thrombosis 
was noticed in the basilic and internal saphena veins of the left side. 
About a week afterwards she cried out one morning after breakfast with 
pain in her head, and shortly afterwards became convulsed. Twitchings 
were noticed in the muscles of the lower part of the face on the left side, 
involving the lips, the angle of the mouth, and the left side of the neck. 
The face was turned to the left. There were also convulsive movements 
of the left arm, more particularly of the forearm, wrist, and hand. There 
were no movements of the leg on that side. The girl died in the course 
of the evening after a series of these convulsive movements. The temper- 
ature was normal throughout. 

On opening the superior longitudinal sinus, after death, the channel 
was found to contain a decolourised adherent clot which reached from 
nearly the anterior extremity to the posterior third. Opening into the 
sinus was a vein which ran from the right cerebral hemisphere. This was 
also filled with a clot, but less decolourised than the first, and the surface 
of the brain in its neighbourhood was the seat of a circumscribed haemor- 
rhage. The clot was bounded posteriorly by the fissure of Rolando, and 
extended anteriorly over the posterior part of the superior frontal convo- 
lution on the right side. These correspond very nearly to the areas de- 
scribed by Ferrier, as connected with the movements of the lips, tongue, 
and mouth ; also that for the movements of the arm and leg. There were 
no convulsive movements of the left leg, but this was the seat of so 



326 DISEASE IN CHILDREN". 

much oedema that the child's own voluntary power over it had been very 
small. 

This case, for the notes of which I am indebted to Dr. Lawrence Hum- 
phry, the resident physician, bears a very close resemblance to Valleix' 
case before referred to, although occurring in a much older child. It will 
be remarked that the temperature during the convulsive seizures was not 
elevated. 

When the extravasation of blood takes place into the substance of the 
brain the first symptom is usually an attack of convulsions. Afterwards 
the phenomena may resemble those peculiar to an apoplectic seizure in the 
adult. It is probable that this form of haemorrhage is less uncommon 
than might be inferred from examinations in the dead-house ; for if the 
amount of blood effused be moderate, the child .may recover with a more 
or less extensive paralysis. In primary haemorrhages I believe this is not 
unfrequently the case. In hospital practice we not unfrequently see chil- 
dren who, as a consequence of a fall or some injury to the head, are seized 
with headache and convulsions, and are then found to be paralysed in one 
half of the body. The leg often recovers after a few weeks, but the arm 
may remain more or less permanently disabled with contraction of the fin- 
gers. This was the case with a little girl, six years of age, who was lately 
a patient in the East London Children's Hospital. In addition the child 
was aphasic, and could not be persuaded to speak during her stay in the 
hospital. Otherwise her general health seemed fairly good, and she did 
not complain of headache. The case unfortunately could not be followed 
out, as after a few weeks the child was removed by her friends ; but I 
have little hesitation in ascribing her symptoms to a small clot in the 
brain. 

Often the cerebral haemorrhage is only one of several lesions occupying 
the cranial cavity. It is then difficult to assign to each its due share in 
the production of the symptoms. 

A little girl, aged fifteen months, with ten teeth, was brought to the 
hospital on July 13th. According to the mother's account the child, 
although hand-fed, had walked at the age of ten months, and had always 
been regarded as healthy until the previous March, when she had had a 
fall down a flight of stairs. The child was not stunned by the accident, 
but vomited and "was ill" for a few days. She then began to lose flesh 
and ceased to run about, always crying to be nursed. On June 4th, she 
had a violent convulsive seizure which began with hiccough. The spasms 
were limited to the left side, and lasted nine hours. When they ceased 
the left arm and leg were noticed to be powerless, and the face was drawn 
to the right side. The paralysis passed off in about a fortnight, but the 
child remained weakly. She began to have a discharge from the left ear 
and the nostrils. She seemed to suffer much from pain in the head ; often 
vomited ; and the bowels were somewhat loose. On two occasions she had 
general convulsions of an hour's duration. She took liquid food well. 

Towards the end of June the child became much worse. She began 
to cough ; her breathing was rapid ; she sighed a great deal; seemed very 
drowsy, and at times would scream out suddenly as if in pain. 

On admission into the hospital (on July 13th) the temperature was 
101° ; pulse, 160 ; respirations, 88. The patient was fretful and screamed 
almost incessantly until 11 p.m., when she had an attack of general convul- 
sions. At this time her temperature was 104°. On the following morning 
she was found very pale ; the fontanelle was depressed ; the eyes were 
turned constantly to the right ; the pupils were unequal and insensible to 



CEKEBEAL HvEMOEBHAGE — SYMPTOMS. 327 

light, the left being the larger of the two. Both arms were convulsed, and 
the right leg and left hand were rigid ; there was no paralysis of the face. 
The hands, feet, and nose felt cold, although the temperature in the tectmn. 
was 102.4°. The pulse was very small, 170. The abdomen was soft and 
not retracted. Pressure on the skin produced little flush. On examina- 
tion of the back dulness was noted on both sides with abundant crepitat- 
ing rales. After this the child remained insensible and died at 6. p.m. 

On examination of the body much yellow lymph was found covering 
the right middle lobe of the cerebrum. There was an old clot, the size of a 
hen's egg, occupying the right corpus striatum and the superjacent part of 
the right hemisphere. Scattered caseous nodules, the size of a large pea, 
were seen in the right hemisphere, and the choroid plexus ; and some gray 
granulations were discovered on the vertex of the brain along the course of 
the vessels, and a larger number at the base. The lungs were the seat 
of catarrhal pneumonia. The liver, spleen, and kidneys contained small 
yellow nodules ; and the bronchial and mesenteric glands were enlarged 
and caseous. 

In this case there can be little doubt that the convulsions and hemi- 
plegia noted on June 4th resulted from the apoplectic clot. The after- 
symptoms were, no doubt, the consequence of the meningitis and general 
tuberculosis. The case is interesting as showing that a copious extravasa- 
tion is not necessarily fatal ; for it is reasonable to suppose that had the 
clot been the sole lesion present the child would not have died. 

Cerebral haemorrhage in the child is not, however, always accompanied 
by symptoms so characteristic. Violent convulsions and sudden death may 
be produced by a clot in the substance of the brain ; or a child may be 
seized with repeated vomiting ; may then be taken with convulsions ; and 
afterwards fall into a state of unconsciousness with dilated pupils, rapid 
feeble pulse, and cool skin, and die in the course of a few hours. These 
were the symptoms noticed in the case of a boy who died in the Victoria 
Park Hospital from rupture of a cerebral aneurism. The notes of the case 
were kindly furnished to me by Dr. Humphry, the resident physician. 

A scrofulous-looking boy, aged twelve years, was admitted into the hos- 
pital under the care of my colleague, Dr. Birkett, on March 15th. He had 
had scarlatina four years before, followed by dropsy, and there was besides 
a doubtful history of rheumatic fever at about the same time. For two 
years the patient had complained of shortness of breath, which had lately 
been getting more distressing. When admitted, a loud mitral murmur 
was detected, with considerable hypertrophy of the heart. 

On March 19th the boy vomited a great deal, and complained of head- 
ache. On the morning of March 20th he seemed very sleepy, but made no 
complaint. At 11.30 a.m. the resident physician was summoned to his bed- 
side, as the boy was said to have had a fit. The patient had vomited, and 
appeared to be very drowsy, but he answered questions. The pupils were 
equal and rather contracted ; the conjunctivae were sensitive, and there 
was no squint or other sign of paralysis. Shortly afterwards he had several 
quasi-fits in which he became flushed. His eyes rolled from side to side, 
and the conjunctivae were not sensitive. He passed water in the bed. 
The pupils were equal. Temperature, 97.6° ; pulse, 84, and regular. xAfter 
this the coma became more and more profound, and the boy died at 4 p.m. 

On examination of the body the veins over both hemispheres were 
much congested, especially on the right side. The pia mater over the 
whole surface was suffused. The left hemisphere was larger than the 
right, and the convolutions were flattened. At the base of the brain all the 



328 DISEASE IN CHILDEEN. 

loose tissue of the arachnoid was filled with dark clotted blood, which had 
spread along the Sylvian fissure on to both surfaces of the cerebellum and 
downwards along the cord. Both lateral ventricles were completely filled 
with a large clot, as also were the third and fourth ventricles. From the 
ventricles the blood seemed to have spread by the transverse fissure to the 
outer portion of the brain, and not through the "iter." The source of 
the haemorrhage was a small aneurism, of the size of a small pea, seated 
on the Sylvian artery about one inch from its beginning. The coats of the 
aneurism were very atheromatous and brittle. The rupture was extensive 
along the top of the aneurism, and the blood had burst into the top of the 
anterior horn of the left lateral ventricle. Elsewhere the coats of the ves- 
sels showed no sign of disease. The mitral valve was much beaded, and 
the pericardium was universally adherent. 

Judging from the variety of symptoms found as a result of cerebral 
haemorrhage in the child we can only conclude that there are none which 
can be considered characteristic of this lesion. Symptoms of irritation of 
the brain coming on suddenly, and followed after a few hours by symptoms 
of compression, are not peculiar to haemorrhagic effusion within the skull ; 
and yet, as a rule, we find nothing more distinctive than these. Still, the 
very fact of profound depression following rapidly upon symptoms of 
violent irritation in a non-pyretic patient may give rise to suspicions of 
cerebral haemorrhage, especially in children over four or five years of age. 

Diagnosis. — On account of the indefinite character of the symptoms, 
haemorrhage into the brain or meninges in childhood is very difficult to 
detect. The difficulty is increased by the lesion being so often a second- 
ary one, occurring in infants and young children who are already suffering 
from other complaints.. It must be confessed that in such cases intra- 
cranial haemorrhage is very likely to be overlooked. Even when the haemor- 
rhage is primary it is difficult to lay down rules for the detection of the 
lesion. 

If a young child, whose water has been examined and found to be 
healthy, be seized with repeated convulsions, in the intervals of which, al- 
though drowsy and stupid, his temperature is normal, and he swallows 
liquid food with appetite, we may hesitate between congestion of the brain 
with effusion of fluid and intra-cranial haemorrhage. If, now, we notice 
that after the stupor has become marked the convulsions continue, and 
especially if any contractions and rigidity, more than merely temporary, 
are noticed in the hands and feet, the temperature remaining low, we are 
justified in suspecting a haemorrhage. 

When hemiplegia follows an attack of convulsions, the paralysis is not 
necessarily a symptom of haemorrhage, for the same phenomena (convul- 
sions and paralysis) are occasionally seen in cases of tumour of the brain. 
In the latter disease, however, we can usually obtain a history of severe 
and paroxysmal headache ; there is often paralysis of ocular muscles, indi- 
cating implication of cerebral nerves ; and an examination of the eye will 
generally detect the presence of optic neuritis. Contractions and rigidity 
of the fingers and toes, wrists or ankles, may occur in either case. If, 
after recovery of consciousness the hemiplegia persist, but the child re- 
main free from headache, if the retinae are normal and the general health 
seem fairly good, a cerebral growth may be excluded. 

A diagnosis between haemorrhage into the meninges and that into the 
substance of the brain is probably impossible from the symptoms alone, 
although if paralysis occur this symptom is not in favour of meningeal 
extravasation. The age, however, is here of importance. Under the 



CEEEBRAL HAEMORRHAGE — DIAGNOSIS — TREATMENT. 329 

third year haemorrhage rarely takes place into the cerebral tissue. In 
nine cases of intracranial haemorrhage occurring in infants aged three 
years and under, observed by M. Legendre, in no case was the haemorrhage 
other than meningeal. After that age haemorrhage more commonly takes 
place into the brain-substance, as it does in the adult. 

Prognosis. — In all cases of cerebral haemorrhage the prognosis is very 
serious ; and it is especially so if the patient in whom the extravasation 
occur be the subject of diathetic disease, or be weakened by recent acute 
illness. The occurrence of paralysis is not in itself a necessarily unfavour- 
able sign. Of greater importance is the degree of heaviness remaining 
after the convulsions have ceased, or the frequency of return of the sj)as- 
modic movements themselves. As long as the child continues to take 
liquid food we may hope for improvement. If he refuse his bottle, or 
cease to drink when the feeding-cup is held to his lips, the sign is a very 
unfavourable one. The condition of the pupils should be always noticed. 
If they are dilated and insensible to light the prognosis is bad ; if they are 
unequal in size death may be considered certain. 

Treatment. — Cases of intracranial haemorrhage require much the same 
treatment as has been already recommended for congestion of the brain. 
If the child be strong an ice-bag should be applied to his head, and the 
bowels should be freely acted upon by a dose of calomel and jalap. If 
the heart's action be violent, and the arteries of the neck are seen to pul- 
sate strongly, digitalis may be given to control the energy of the cardiac 
contractions. Three drops of the tincture of digitalis, or twenty of the 
infusion, may be given every two or three hours to a child of twelve 
months of age. The patient should lie with his head raised ; and if the 
feet are cold, a hot bottle can be placed at the bottom of the cot. If the 
pulse flag or the fontanelle become depressed, stimulants should be given 
in such quantities as may seem desirable. 

The food should consist of milk, freely diluted with barley water, or of 
whey and barley water. It is better in these cases to feed the child with 
a spoon, or at any rate to give him fluid only in small quantities at a time, 
so as not to increase the strain upon the vessels by a rapid introduction of 
large quantities of liquid into the circulation. 

In the after-paralysis little can be done. Our efforts must be re- 
stricted to ordinary measures for improving the general health and pro- 
moting nutrition. 



CHAPTER XI. 

CEREBRAL TUMOUR. 

Children, like adults, are subject to morbid formations in the brain 
which may give rise to a variety of symptoms according to the situation of 
the growth. In the case of a child, however, "tumour" of the brain 
usually means "tubercle" of the brain, for it is only in exceptional cases 
that any other form of cerebral growth is to be found. Still, in rare in- 
stances cancerous, glyomatous, and syphilitic nodules are developed in this 
region, and occasionally we meet with the cysticercus cellulosa or the 
hydatid cyst. 

Morbid Anatomy. — Tubercle of the brain is said to be rare under the 
age of two years ; but I think the occurrence of the disease in infants is 
more common than has been supposed. It is seldom seen in the cranium 
without other organs being similarly affected, although in exceptional 
cases it may be a solitary instance of tubercular formation in the body. 
The seat is most frequently in the cerebellum, but it is also common in 
the hemispheres of the brain. Next in order of frequency, according to 
Andral, come the pons, the medulla oblongata, the peduncles of the 
cerebrum and cerebellum, the optic thalamus, and the corpus striatum. 
In number there may be one or more, and in size they may be small or 
large. Usually the more numerous masses are of small dimensions. 
Single tumours may be as small as a pea or as big as an egg, or even of 
still larger size ; but they are most commonly met with about equal in 
volume to a filbert or small marble. The masses are almost always sur- 
rounded by a fibrous covering which separates them from the brain-sub- 
stance around. In exceptional cases, however, i.e., where death has taken 
place while the tumour is still growing, the limits of the mass are not 
thus circumscribed, but its substance passes insensibly into the adjacent 
cerebral tissue. When the tumour ceases to extend itself, an areola of 
connective tissue and vessels forms at its circumference, and develops 
into a fibrous envelope which varies in thickness according to the age of 
the growth. 

On section the tumours are yellowish white, or have a faint greenish 
tint, and are found to consist of cheesy matter. Their consistence is 
more or less firm, but the centre is usually softer than the circumference, 
and may be converted entirely into a creamy pulp so as to give the appear- 
ance, with the firm envelope, of a little bag of pus. Tuberculous matter 
found in the brain is seldom seen in any other shape than that of yellow 
caseous matter. Lebert and Bokitansky, however, agree that in excep- 
tional cases it may begin as the gray granulation ; but it seldom remains 
long in this stage and very quickly becomes cheesy and yellow. Around 
the mass the brain-substance may be natural, or congested, or more or 
less softened by oedema. Often the collections of tubercle spring from the 
pia mater, and are attached to it by a fibrous stalk continuous with the 



CEREBRAL TUMOUR — MORBID ANATOMY— SYMPTOMS. 331 

envelope, and filled like it with tuberculous or cheesy matter. Tuber- 
culous meningitis is often present, and is the direct cause of death. If 
the mass be on the surface of the cerebellum, and so placed as to press 
on the straight sinus or the vena magna Galeni, it may be a cause of 
chronic hydrocephalus. It is not often that a cretaceous change takes place 
in cheesy matter situated in or upon the brain, for the irritation set up is 
usually so injurious that death takes place before this transformation has 
had time to occur. Still, it is sometimes met with. 

Cancer of the brain is rare. When it occurs it is usually secondary to 
a similar growth in the eye ; or, as recorded by Steiner, may advance in- 
wards from the skull. When thus secondary, it may appear in several 
centres. The size of the mass varies from a pea to an orange. These so- 
called cancerous growths have usually the characters of sarcoma. 

Gliomatous tumours of the brain are solitary growths which increase 
slowly in size, so that they may be long in producing appreciable effects. 
They often reach considerable dimensions, and occupy by preference one 
or other of the posterior cerebral lobes. Their borders are not well 
defined, and their substance passes gradually into the brain-tissue around. 
Their consistence is usually firm, and they are rather more vascular than 
the cerebral substance in which they are embedded. 

Cysticerci, the second stage of the taenia solium, when they occur in 
the brain, are usually numerous. They are generally found in the gray 
substance or at the surface. They are especially partial to the pia mater, 
and are usually more or less embedded in the gray matter of the convolu- 
tions. They vary in size from a pea upwards. Occasionally they die and 
become changed into a thick "mortar-like" substance containing booklets. 

Hydatids, the second stage of the tsenia echinococcus, usually exist, 
several together, enclosed in an outer sac. The most frequent situation is 
the centre of the white matter in one of the hemispheres, and the cyst 
may grow to a large size. The hydatid, although rare at all ages, is not 
proportionately less common in children than in adults. In twenty-four 
cases of hydatids of the brain, collected by Dr. Bastian, in which the age 
was stated, three occurred in children under the age of ten years. 

Symptoms. — Tumours of. the brain, if they grow slowly, if they are 
situated at a distance from the base of the brain and the large ganglia, and 
if they merely displace the brain filaments without destroying them, may 
produce absolutely no symptoms at all. This fact, which has been ascribed 
to a supposed faculty of accommodating itself to pressure residing in the 
brain, is better explained bj r Niemeyer to be due to the atrophy of cerebral 
substance which takes place in the neighbourhood of slowly growing 
tumours, allowing of increase in size of the growth without interference 
with cerebral function. Sometimes the symptoms are so trifling as to be 
overshadowed by others arising from disease or disturbance of a different 
part of the body. Again, after being a long time latent, the growth may 
give rise to obstinate headache, to a slight squint, or some other form of 
muscular spasm ; and for weeks or months this may be the only symptom 
to be detected. In cases where the morbid growth consists of cheesy 
matter other symptoms may arise not due directly to the cerebral tumour. 
Thus the patient often dies of a tubercular meningitis, the symptoms of 
which may quite conceal any special phenomena resulting from the tumour 
of the brain. 

There are no symptoms peculiar to an intracranial growth, for all are 
the consequence of local destruction of substance, of pressure on the tissue 
around, and of interference with its vascular supply. A distinctive char- 



332 DISEASE IN CHILDREN. 

acter is, however, given to the disease by its course, the sequence of its 
phenomena, and the predominance of some symptoms over others. 

There are certain general symptoms which are found in most cases of 
cerebral tumour. Headache is usually early to occur, and may remain for 
a long time the sole morbid phenomenon. Often slight at first, it becomes 
gradually more intense, and may assume a violent paroxysmal character 
which is Infinitely distressing. Infants show this by contracting the brows, 
throwing up the hand to the head, rolling the head from side to side, and 
occasionally breaking out into piercing cries. An older child will place 
his hand upon the site of the pain if asked to do so. He avoids the light ; 
shudders at a loud noise ; and often buries his face in the pillow of his 
bed, or covers his head with the bedclothes. The attacks of headache are 
generally accompanied by vomiting, and often by dizziness. 

Sooner or later convulsions, tonic or clonic, may supervene. These 
are sometimes complete and bilateral, and resemble attacks of epilepsy. 
Sometimes they are partial, and are confined to the face, the eyes, or one 
limb. The convulsions may be preceded by tremours or twitchings without 
loss of consciousness, and it may happen that these latter are present with- 
out being followed by more decided seizures. If attacks of such motor 
disturbance, of whatever degree, are noticed from time to time in the same 
part, or persist in it, the symptom is a very suspicious one. Convulsions 
are said to be more common when the growth is situated in the posterior 
lobes of the brain, and to be less frequent when the anterior lobes are 
affected. If the seizures are epileptiform in character, the tumour is proba- 
bly in or near the cortical substance of the cerebrum. 

The convulsions may be followed by temporary paralysis in the affected 
muscles, and in some cases a permanent paralysis may be observed. This 
more commonly affects muscles supplied by cerebral nerves than is the 
case in other diseases of the brain. The external rectus may be affected 
(sixth nerve), producing convergent squint ; there may be ptosis, dilatation 
of pupil, and external strabismus from paralysis of the third nerve ; the 
facial muscles may be paralysed ; and there may be impairment of deglu- 
tition or articulation. Sometimes hemiplegia is produced. The cerebral 
nerves are affected on the same side as the growth : the spinal nerves on 
the opposite side. If, however, there be several tumours present in the 
brain, nerves of both sides may be involved, and we may find hemiplegia 
combined with variously distributed paralyses on both sides of the face. 
Generally the paralysis is developed slowly, and is preceded by pain in the 
muscles about to be affected. When it occurs suddenly after a convulsive 
seizure, the case is often mistaken for one of cerebral haemorrhage. Con- 
tractions often occur in the paralysed muscles, and may follow the paralysis 
very rapidly. 

There is usually loss of special sense. Deafness may occur, and im- 
pairment of vision is a frequent symptom. Amaurosis is said to be most 
common when the growth occupies the anterior lobes ; in which case the 
straight sinus is compressed and the escape of blood obstructed from the 
veins of the eye. Impairment of vision is not, however, confined to these 
cases. It is often seen when the tumour is seated in the posterior lobes or 
in the cerebellum. The disturbance of sight is then attributed to com- 
pression of the vena magna Galeni ; and the interference with the circula- 
tion induces at the same time a copious effusion into the lateral ven- 
tricles. 

Ophthalmoscopic examination of the eye almost always shows impor- 
tant changes which affect the retina of both eyes. We find that the disk 



CEEEBEAL TUMOUK — SYMPTOMS. 333 

is swollen and blurred at the margins, with tortuosity of the central vein. 
If the child live long enough the optic nerve may atrophy. 

Unless chronic meningitis become developed, or there are numerous 
tumours in the cerebral substance of both hemispheres, intelligence is but 
little affected. Still the child generally shows some change in character. 
He is fretful and perverse, or morose in temper, and gives much trouble 
in the nursery and school-room. 

In slowly growing tumours the development of the symptoms is very 
gradual. These are the cases which are comparatively easy to recognise. 
We find a history of headache, of tremors, or convulsive attacks, followed 
at a longer or shorter interval by paralysis more or less complete, involv- 
ing often special senses, and implicating the cerebral nerves as well as those 
of the spine. 

A good illustration of the symptoms is seen in the following case : 

A little boy, aged five years and a half, who had had a slight conver- 
gent squint since the age of two years, but had otherwise enjoyed perfect 
health, began to suffer in the month of June from peculiar symptoms of 
illness. A short time previously he had had a severe fall upon his head. 
The accident shook him for a time, but its effects appeared to pass off com- 
pletely. Early in June, however, the boy began to complain of headache, 
which came on in severe paroxysms, so that he cried out with the pain. 
Almost at the same time his limbs began to get weak. His arms trembled 
when he took anything up in his hands, and he tottered as he walked. 
Very soon afterwards his sight began to fail, and he used to vomit, espe- 
cially at night ; but his other senses seemed perfect, and his intelligence 
was unimpaired. After a time the severity of the headache diminished, 
but the other symptoms were intensified, so that by November, when he 
was admitted into the East London Children's Hospital, he was almost 
blind and had quite lost the power of walking. 

On admission (November 16th) the muscles were well nourished and 
seemed firm, but any voluntary movement excited a kind of spasm, during 
which both arms were drawn up, seemed to get rigid, and were agitated 
by a peculiar trembling which lasted for one or two minutes. The legs 
also appeared very weak. When placed upon his feet he could not stand 
without support, and when he tried to do so a tremor was noticed in the 
legs like that which affected the arms. There was no paralysis of the face, 
and the tongue was protruded in the middle line. He had only partial 
control over his sphincters, for when he felt the desire to evacuate the 
bowels or the bladder, he usually passed his water or motions in the bed 
before there was time for any one to come to his assistance. He was quite 
blind, and an ophthalmoscopic examination showed the presence of optic 
neuritis. His other senses were perfect, and his intelligence was quite 
equal to that of other children of his age. His temperature at 9 a.m. was 
102° ; pulse, 138. 

For some days after admission the boy continued in much the same 
state. The temperature remained between 100° and 101°, rather higher 
at night than in the morning. The tremors persisted, and the weakness 
became more and more marked. In about ten days, however, some rigidity 
of the left arm was noted. The elbow became slightly stiff, and he kept 
his left hand tightly clenched over the inverted thumb. He used only the 
right hand voluntarily, although if made to hold anything in the left he 
could do so. 

On November 28th control over the sphincters was quite lost, and he 
passed his water in the bed. The bowels were usually costive. There was 



334 DISEASE IN CHILDREN. 

rigidity and tremor of both arms, the head was retracted, and the back 
was kept rigidly extended. Still, intelligence remained unimpaired. Some- 
times the boy answered questions in a sleepy tone, but he perfectly under- 
stood all that was said to him. He made no complaints. Temperature at 
9 a.m., 104.6° ; pulse, 144. At 6 p.m., temperature, 104.4° ; pulse, 148. 

On November 29th he became very drowsy and would answer no ques- 
tions. Both arms were rigid and flexed, with the thumbs twisted inwards. 
The legs also had become stiff and the toes extended. The back was rigid 
with inclination to opisthotonus. He could swallow, but apparently with 
difficulty. The respiration was jerking, and appeared to be chiefly dia- 
phragmatic. The abdomen was rather retracted. The eyeballs twitched. 
The child was alternately flushed and pale, with profuse perspiration. He 
had several convulsive attacks during which the left corner of his mouth 
was drawn up. Temperature at 9 a.m., 108°. The boy had no more fits 
after 2 p.m., but lay unconscious with his eyes fixed and turned to the 
right. There was oscillation of the eyeballs, and the pupils were dilated 
and immovable. He winked when the right eye was touched, but the left 
conjunctiva was insensible. The joints were rigid and flexed. The belly 
was retracted. The pulse was excessively rapid and very irregular in force 
and rhythm. Respiration 36, with occasional deep sighs. The child died 
the same night in convulsions. The temperature shortly before death was 
108.8°. 

On examination of the body the brain weighed fifty ounces. The con- 
volutions were flattened, especially over the right hemisphere. On remov- 
ing a thin layer of brain-substance at the posterior part of this hemisphere 
a large cavity was found of between two and three inches in diameter. This 
was empty and was lined by a species of false membrane. The brain-sub- 
stance composing its roof seemed rather firmer than natural, and was from 
one-sixth to one -fourth of an inch in thickness. The floor of the cavity was 
formed by a firm lobulated tumour as large as a good-sized orange. This 
reached to the base of the skull, where it was firmly attached to the dura 
mater. It lay external to the pons, occupying the posterior part of the 
middle lobe and the adjacent part of the posterior lobe. Its boundaries 
were not distinctly defined, for it passed insensibly into the cerebral sub- 
stance around. On section the mass showed a uniform surface of a yel- 
lowish-white colour. It was generally very firm to the touch, but spots were 
found here and there where the substance was softer, as if from fatty de- 
generation. Some of these softened spots had become hollowed out into 
cavities of about the size of a marble, with irregular walls. On microscopi- 
cal examination the tumour was found to consist of small round cells, with 
many spindle-shaped cells and a fibrous matrix. There were also many fat 
globules. The lateral ventricles contained about eight ounces of fluid. 
The crura cerebri were softened, flattened, and rather twisted. The cor- 
pora quadrigemina also softened. Optic nerves small and soft. There was 
no appearance of recent meningitis. 

This case illustrates fairly well the course of the disease. The severe 
paroxysms of headache with which the illness began, the vomiting, the 
affection of sight, the gradually increasing paralysis, and the muscular con- 
tractions and spasms which succeeded, together with the chronic progress 
of the case, all pointed to compression of the cerebral substance. It is 
probable that the effusion into the ventricles was a late symptom, only oc- 
curring when the retraction of the head and dorsal rigidity became marked. 
The accumulation of fluid compressed the cerebral substance, and was a 
cause of the drowsiness and stupor which marked the last hours of the 



CEREBRAL TUMOUR — SYMPTOMS. 335 

boy's illness. The complete clearness of mind which continued until a 
late period in the course of the disease is worthy of note in the case of so 
large a growth. A curious point in the case is the continuous elevation of 
temperature ; for pyrexia is not a usual symptom in gliomatous tumours of 
the brain until quite the close of the illness, unless the growth be compli- 
cated with meningitis, and in this case no recent signs of inflammation 
could be discovered. On account of this pyrexia the tumour was thought to 
be a tubercular one, although no evidence of tubercle could be obtained 
during life by examination of the other organs of the body. 

In the case of children it is exceptional to find any other variety of tu- 
mour than the tubercular form. This, in the majority of cases, becomes 
sooner or later complicated with tubercular meningitis, the symptoms of 
which will then mix with and obscure the more special jihenomena con- 
nected with the cerebral growth. Anomalous cases of tubercular menin- 
gitis are often, as Dr. Hennis Green pointed out in his admirable paper, 
instances of this combination. 

A little girl, twelve months old, was noticed towards the beginning of 
March to squint outwards with the left eye, and shortly afterwards the 
eyelid of that side began to droop. Much about the same time she suf- 
fered from sickness, and was restless and agitated, often screaming out as 
if in pain. The face used to flush, often on one side only. She took her 
bottle well. The bowels were confined. At the beginning of April the 
restlessness from which she had suffered increased, and she cried greatly, 
rolling her head from side to side on the pillow. She then had a fit in 
which both arms and legs were rigid and convulsed ; her head was re- 
tracted and her back arched. After this she did not completely recover 
consciousness, and, either from dulness of intelligence or from impaired 
vision, ceased to recognise her mother. She still, however, took her bottle 
well when the teat was put into her mouth. 

When seen, on April 23d, the child lay in her cot apparently uncon- 
scious. The head was retracted and the back rigid ; the arms were stiff 
and semiflexed, with the thumbs inverted ; the big toes on each side were 
rigid and extended ; but while the left lower limb lay stiff and straight 
the right was slightly flexed, and the leg from the knee downwards was in 
constant movement, alternately flexed and extended. There was ptosis of 
the left eye, but no squint. The pupils were unequal and insensible to 
light, the left the more dilated. The breathing was irregular, with sighs 
and pauses. Temperature at 6 p.m., 99°. The child took her bottle well, 
but lay as if unconscious, although the pupils contracted when the con- 
junctivae were touched. After this the rigidity continued with occasional 
remissions, and an external squint became again developed in the left eye. 
The temperature varied between 99° and 100.5°. 

At the beginning of May the patient began to cough, and a pneumonic 
consolidation was discovered in the right lung. After this she became 
rapidly worse ; the coma became deeper ; the temperature rose to 103° ; 
and she died on May 11th. 

On examination of the body there was found a consolidation breaking- 
down in the right lung with many gray granulations. The convolutions of 
the brain were flattened and congested. Its substance was excessively soft, 
so that the brain did not preserve its shape when removed. The lateral 
ventricles contained eight ounces of clear fluid. Attached to the under 
surface of the left crus cerebri was a nodulated tumour of the size of a 
walnut, feeling soft to the touch like a bag of pus. It was irregular on 
the surface, and was attached to the crus by a slender stalk of soft, yellow 



336 DISEASE IN CHILDREN. 

cheesy matter, and covered with pia mater. No gray granulations could 
be detected about the membranes, but the dura mater was reddened and 
thickened. 

In this case the occurrence of signs of paralysis of the left third nerve 
(ptosis and external strabismus), accompanied by headache and vomiting, 
pointed to localised pressure, such as that of a growth ; and as this nerve 
and no other was affected at the first, the position of the growth in or 
upon the left crus cerebri (which is pierced by the oculo-motor nerve) 
could be positively indicated. The other symptoms — convulsions, rigidity, 
and stupor — which followed after an interval are such as are common in 
cases of cerebral tubercle, and almost invariably attend the close of the ill- 
ness. In fact, such symptoms, preceded during several months by head- 
ache, vomiting, and paralysis of a cerebral nerve on one side, are very 
characteristic of tubercle of the brain. The disease might, indeed, be 
often divided into two stages — an early chronic stage, in which headache, 
vomitiDg, optic neuritis, tremors and convulsive movements, and more or 
less marked muscular weakness succeed one another irregularly and at 
various intervals of time, and into an acute second stage, in which con- 
vulsions, paralysis, rigidity of limbs, retraction of head, and stupor usher 
in the end of the illness. We must not, however, always expect to meet 
with a division of the disease into two well-defined stages. Sometimes 
the earlier course of the malady is accompanied by few symptoms, and 
these, on account of the tender age of the child and the character of the 
symptoms themselves, may have little importance attached to them. 

Thus a little girl, aged six months, had vomited more or less since 
birth, and was said to moan frequently and " fret " as if in pain. She had 
wasted considerably but had never had convulsions. The family history 
was a healthy one. 

In so young a child vomiting, pain, and restlessness, combined with 
loss of flesh, are familiar symptoms, and do not point in any way to intra- 
cranial disease. But on examining the baby carefully it was noticed that 
when the child cried the mouth was drawn up to the left side, and that 
the left eyebrow contracted better than the right. When the face was at 
rest the right eye was more open than the left, and the nasal line skirting 
the angle of the mouth was less deep on the right side of the face. The 
pupils were equal and there was no squint. 

In a few days other symptoms began to be observed. The head became 
retracted, there were tremulous movements in the right arm, the child 
seemed heavy and stupid, and often appeared to be quite unconscious. 
Eigidity of the limbs then came on, the drowsiness deepened into coma, 
and the child died. After death patches of meningitis were found at the 
base of the brain. A small cheesy mass, the size of a cherry-stone, was 
imbedded in the substance of the pons — the left posterior half — and a 
second, pedunculated, growth of the size of a marble was attached to the 
upper part of the medulla oblongata and lay underneath the right crus 
cerebri. There was a considerable amount of fluid in the ventricles, and 
a mass of caseous glands in various stages of softening lay about the roots 
of the lungs. 

Sometimes the disease begins with extensive paralysis. This was the 
case with a little girl, aged four years, in whom the first symptoms noticed 
were left hemiplegia and vomiting four or five months before her death. 
In other cases the onset of the illness may be indicated by a muscular tre- 
mor or a convulsive attack. In the majority of instances, however, severe 
headache precedes the other symptoms. 



CEREBEAL TUMOUR —SYMPTOMS — DIAGNOSIS. 337 

On account of the frequency with which tubercle occupies the cerebellum 
in children it is important to be aware of the phenomena which usually 
accompany a growth situated in this region of the brain. The characteristic 
group of symptoms consists of vomiting, occipital headache, amaurosis, 
and a staggering gait. 

The vomiting is especially obstinate. It is a frequent accompaniment 
of all cerebral tumours, but when combined with occipital pain is very sug- 
gestive of a cerebellar growth. The headache is the consequence of pres- 
sure upon and stretching of the tentorium. It affects the occiput especially, 
and may radiate to the back of the neck. If, as sometimes happens, it is 
accompanied by rigidity of the muscles of the nucha, we find a curious re- 
semblance to cervical caries which may be a source of perplexity. Amau- 
rosis from optic neuritis is a common symptom of this as well as of all other 
forms of intracranial tumours, but growths in the cerebellum are especially 
apt to press upon the venous channels in the neighbourhood and impede 
the escape of blood from the retina. Staggering gait is the most charac- 
teristic symptom of cerebellar tumour, and when combined with the preced- 
ing is sufficient to establish a diagnosis. Dr. Bastian compares the walk 
of such patients to that of one who paces the deck in a rough sea. In the 
case of a child it looks as if the patient were only now learning to walk, 
and if combined, as it often is, with a certain stiff way of carrying the head, 
the effect in the elder children is very curious. After a time the weakness 
extends to the limbs, which then become unable to support the trunk. 
Tonic contractions, too, may affect the muscles of the back and limbs as 
well as those of the nucha, and are sometimes very severe. Tonic rigidity 
is much more common than clonic convulsions when the tumour affects this 
region of the brain. Dr. Stephen Mackenzie lays it down as a general rule 
that "tonic contraction is a product of cerebellar, clonic of cerebral dis- 
ease." These contractions, like the paresis, affect the muscles of the trunk 
before those of the limbs. 

The pons and' medulla oblongata are also frequently visited by tuber- 
culous formations. In the former situation the growth may produce neu- 
ralgia, anaesthesia, or paralysis of the fifth nerve, difficulty of deglutition, 
and disturbance of the function of the bladder. If the growth occupy the 
anterior lateral half, the third and fourth nerves may be paralysed. If it 
lie in the posterior lateral half, there may be paralysis of the fifth and facial 
nerves, and in either case there may be hemiplegia of the oj^posite half of 
the body. 

In the medulla oblongata the growth may produce wide-spread mis- 
chief. Extensive paralysis is common ; there may be difficulty of degluti- 
tion and articulation and incontinence or retention of urine from paralysis 
of the bladder. Convulsions are common in these cases. 

Tuberculous tumours, when they occur in infants, are almost invariably 
a part of a general formation of tubercle in the body. They are very apt 
to be complicated with catarrhal pneumonia excited Iry the presence of 
the gray granulation in the lungs, and in a large proportion of these cases, 
as has been said, the illness closes with all the signs of the third stage of 
tubercular meningitis. In older children the formation of tubercle may 
not be general. Still, we often find evidence of scrofulous consolidation 
of lung, or caseous bronchial glands, and in such cases the cerebral mass 
might, perhaps, be more strictly described as scrofulous cheesy matter 
than true tubercle. In exceptional cases no other sign of disease is to be 
found in any part of the body. 

Diagnosis. — The existence of a tumour of the brain can only be ascer- 
22 



338 DISEASE m CHILDEEK. 

tained by careful attention to the course of the illness and the character- 
istic grouping of symptoms to which it gives rise. If the combination of 
headache, vomiting, and double optic neuritis be discovered, it is highly 
probable that a cerebral growth is present ; but in infants, although the 
existence of headache and vomiting is easy to ascertain, an ophthalmo- 
scopic examination of the eyes is often a far from easy matter, and even 
the question of impairment of sight may be a difficult one to decide. It 
is probable that many instances of supposed dulness of mind at this early 
age are really instances not of imbecility, but of blindness. The child 
ceases to recognise familiar faces because he has ceased to see them. In 
such cases the test of a bright light passed before the eyes is a very valu- 
able one ; for if the eyes follow the light the infant is evidently not un- 
conscious, and the retina is usually still capable of appreciating a lumi- 
nous jet, although its sensitiveness to ordinary objects is impaired. If then, 
in an infant who is subject to headache and vomiting, we can ascertain in 
addition that the sight has failed, we have gone far to establish the exist- 
ence of tumour. If now a local paralysis arise, or tremors or convulsive 
spasms are noted in special muscles, we may feel satisfied that our diag- 
nosis is a correct one. 

If a young child is seen first towards the close of the disease when the 
symptoms have become complicated with those of basilar meningitis, we 
must inquire carefully as to the previous course of the illness and the 
progression of the symptoms. If we find a history of chronic disease in 
which headache, sickness, and local paralysis, such as squinting, ptosis, or 
distortion of the face, have occurred some months previously ; if any loss 
of power observed has been persistent ; and especially if we can discover 
that the child is the subject of optic neuritis, or that his sight has been 
failing, we may give a positive opinion that a tumour is present in the 
brain. Even the anomalous course of a tubercular meningitis is suspicious 
of a cerebral growth, and the sudden appearance of symptoms character- 
istic of the third stage of this disease (convulsions, stupor, squinting, un- 
equal pupils, paralysis, or rigidity of joints), preceded by signs of chronic 
nervous disturbance, are very suggestive of tubercle of the brain. 

In older children the combination of headache, vomiting, and optic 
neuritis is very significant if Bright's disease can be excluded. Severe 
headache alone is of no value, for migraine is a not uncommon complaint 
in young persons. The disease does not, however, always begin with pain 
in the head. When this symptom is absent, tremors or muscular spasms 
occurring repeatedly in the same limb or the same region of the body are 
suspicious. If after a time they become more severe and general, and are 
complicated with other signs of nervous disturbance, such as paralysis, 
especially of a cerebral nerve, and impairment of sight, the disease is in 
all probability tumour of the brain. 

The actual position of the new formation can seldom be more than 
suspected. In the case of a cerebellar growth, the symptoms to which 
this gives rise have been already described. When the tumour occupies 
the base of the brain, paralysis of some special cerebral nerves may reveal 
the seat of pressure. In other parts of the brain the symptoms are so 
often contradictory, and are so liable to be altered and confused by dis- 
turbing causes, that the situation of the tumour can seldom be predicted 
with anything approaching to certainty. 

If epileptiform attacks form part of the symptoms, these are distin- 
guished from genuine epilepsy by remarking that between the attacks the 
patient is not well, but still continues to exhibit signs of cerebral irritation. 



CEREBEAL TUMOUR— DIAGNOSIS— PROGNOSIS. 339 

With regard to the nature of the growth : A tumour of the brain is in 
childhood so generally tubercular that we may conclude it to be so unless 
there be signs to make us suspect the contrary. If, however, the child be 
well nourished and of sturdy build, if there be no history of phthisis in 
the family, and if the other organs appear to be healthy, we should hesi- 
tate to class the growth as a tubercular one. Children with tubercle of 
the brain are not necessarily wasted, nor have they always a tubercular or 
phthisical history ; but they are usually pale and flabby, and generally show 
in their physical conformation signs of diathetic influence. No argument 
can be founded upon the age of the child, for although the disease is said 
to be rare under the age of two years, I cannot agree with this statement. 
Indeed, in the preceding pages I have referred to two cases — one a little 
girl of twelve months and another aged six months, both patients of my 
own in the East London Children's Hospital — in each of whom tubercular 
masses were found after death connected with the brain. 

Prognosis. — The disease is so fatal a one that when we are satisfied of 
the existence of a tumour of the brain, we can have little expectation of 
the child's recovery. In very rare cases shrinking and calcification of a 
tuberculous tumour have been known to occur ; but if the growth has 
produced symptoms of pressure and irritation, little hope can be enter- 
tained of a favourable ending to the illness. Even in cases where the 
symptoms, although distinct, are of a mild character, we must not allow 
ourselves to anticipate necessarily a lengthened course to the disease, for 
however chronic may have been the earlier symptoms, the disease may at 
any time take on a more acute course and run rapidly to a close. 

Treatment. — In the treatment of these cases we must attend to the con- 
stitutional condition of the child and correct any derangement which may 
be present to interfere with the nutritive processes. We must remedy 
any digestive disturbance and regulate the bowels. By improving the 
general health of the patient we may perhaps help to arrest the extension 
of the mass, and may possibly promote the calcification of the tumour. 
The child should live, if possible, in a dry bracing air ; should be warmly 
clothed, judiciously fed, properly exercised, and be treated generally ac- 
cording to the rules laid down for the management of the scrofulous dia- 
thesis. Cod-liver oil and iodide of iron are useful aids to this treatment. 
If any history of syphilis can be obtained, mercurial treatment must be 
adopted without loss of time, and a long course of perchloride of mercury 
should be entered upon. Distressing symptoms must be treated as they 
arise. Vomiting can be often allayed by keeping the child perfectly quiet 
in a recumbent position, and by applying an ice-bag to the head. Cold 
applications will also relieve the headache when this becomes severe, and 
a good aperient of calomel and jalap is useful. If necessary, morphia can 
be given with the same object. 



CHAPTER XII. 

CHRONIC HYDROCEPHALUS. 

Hydkocephalus is a name given to serous effusions into the cavity of the 
skull, wherever situated. The effusion may be acute or chronic. Acute 
hydrocephalus is generally the consequence of tubercular inflammation of 
the meninges of the brain, and the name is practically synonymous with 
tubercular meningitis — a disease which is discussed in a separate chapter. 
It is not, however, very uncommon in cases of death from severe and pro- 
tracted convulsions, occurring without discoverable organic lesion of the 
nervous centres, to find collections of serosity in the cerebral ventricles 
and at the base of the brain. This effusion is accompanied by turgescence 
of the veins of the pia mater — itself probably a consequence of the convul- 
sive seizures — and may be looked upon as a result of the venous conges- 
tion. This may be considered an instance of the non -tubercular form of 
acute hydrocephalus. Such a case is narrated in the chapter on "Convul- 
sions." 

Chronic hydrocephalus is called either internal or external, according 
to the situation of the fluid. In the internal form the fluid is contained in 
the cerebral ventricles ; in the external variety it collects in the arachnoid 
cavity. The disease may be congenital, or may be developed at some 
period after birth. Hence there are two chief divisions of chronic hydro- 
cephalus into the congenital and acquired variety. The congenital form 
is usually an internal hydrocephalus, for the fluid is for the most part in 
the ventricles. In the acquired variety it may be either internal or ex- 
ternal, or the fluid may collect in both situations. 

Causation. — It is difficult to say what may be the causes of congenital 
hydrocephalus, although these are probably more than merely temporary 
agencies ; for a woman who has once given birth to a hydrocephalic infant 
may do so again in future pregnancies. The tendency appears to be often 
hereditary, and it has been attributed with a doubtful amount of probability 
to drunkenness and other constitutional vices on the part of the parents. 
According to Dr. B. Kennert, of Frankfort, the children of workers in lead 
who have themselves suffered from chronic lead-poisoning are very apt to 
develope chronic hydrocephalus. Sometimes it is associated with malfor- 
mation of the brain, for if there is congenital atrophy of any part of the 
organ fluid is thrown out to fill up the resulting space. This has been 
called "hydrocephalus a vacuo." Kokitansky attributes the large majority 
of cases of the congenital form of the malady to inflammation of the arach- 
noid lining of the ventricles occurring during foetal life or attacking the 
infant shortly after birth. 

Acquired hydrocephalus usually occurs before the end of the third 
year. It may be induced by any cause which interferes with the cerebral 
circulation, such as tumours pressing upon the venae Galeni or straight 
sinus, and so impeding the escape of blood from the ventricles. Serious 



CIIKONIC HYDKOCEPHALUS — MOEBID ANATOMY. 341 

pressure upon the veins of the neck by enlarged glands may produce the 
same result. So also the intracranial effusion may be a part of general 
dropsy dependent upon disease of the heart. 

Another group of causes are those which modify the quality of the 
blood. Thus it may occur as a consequence of anaemia, rickets, and 
other diseases which are accompanied by impoverishment of the blood, 
and as a sequel of exhausting acute illness. In Blight's disease hydro- 
cephalus may be a part of the general dropsy induced by the state of the 
kidney. The fluid in acquired hydrocephalus is usually in the ventri- 
cles. In the rare cases where it is found external to the brain it is some- 
times a' consequence of meningeal haemorrhage. In the chapter on this 
subject it was stated that an arachnoid clot becomes after a time, if the 
child survive, converted into a cyst by the adhesion of the edges of the 
layer of fibrine — left after absorption, of the colouring matter of the blood 
— to the serous membrane. This false membrane, according to Legendre, 
Rilliet, and others, is formed, as above described, directly out of the blood- 
clot. Virchow, on the contrary, is of opinion that it results from an in- 
flammation of the internal surface of the dura mater, and that the exuded 
lymph arising from this process becomes vascularised and forms a pseudo- 
serous membrane which is the wall of the cyst. 

The cyst may be simple or loculated, and its contents consist of red- 
dish serum with small clots and flocculent matters. Often the cyst is 
double, each half corresponding to one of the hemispheres of the brain. 
Its walls become thin and transparent, and have a serous appearance. 
Usually arborescent vessels may be seen to ramify on the surface. The 
fluid contents become increased in quantity after a time, and may vary 
from a few spoonfuls to half a pint or more. 

Morbid Anatomy. — When the hydrocephalus is congenital and the fluid 
accumulates in the ventricles of the brain, it tends to press outwards the 
walls of those chambers. As a consequence the brain-substance is thinned ; 
the convolutions are flattened, and, as the pressure is equal in all direc- 
tions, the corpora striata and optic thalami are flattened, separated, and 
pressed aside ; the septum lucidum is softened, stretched, and often torn ; 
the ventricles communicate freely through the dilated foramen of Monro, 
and the corpora quadrigemina, the cerebellum, and the pons are flattened 
and compressed. The membrane lining the ventricles is often found 
thickened and softened, and may be roughened or even distinctly granu- 
lar. In some cases the foramen of Majendie is closed. If the effusion is 
large the walls of the skull also feel the effects of pressure. The head 
becomes distended ; the frontal bone is pushed forwards ; the roofs of the 
orbits are depressed so as to flatten the sockets of the eyeballs, and the 
occipital bone and the squamous portion of the temporal bone are made 
almost horizontal. The sutures are widened and the enlarged fontanelles 
communicate by the sagittal suture. The shape of the head is often not 
quite symmetrical, neither is it globular. The curve is much greater at 
the sides, and the skull is rather flattened at the vertex. Ossification in 
the cranial bones is delayed, and is said to be often aided by the conjunc- 
tion of small islets of bone formed in the membranous interspaces. At a 
later stage the bones become very thick and the skull is remarkably spher- 
ical in shape. 

If no great quantity of fluid is present the size of the head is not in- 
creased, but this is comparatively seldom the case ; usually the skull is 
distended as described. The fluid is clear or slightly turbid, and varies in 
quantity from a few ounces to several pounds. It is of higher specific 



342 DISEASE m CHILDREN. 

gravity than the cerebrospinal fluid ; is alkaline in reaction, and contains 
a very feeble proportion of albumen, besides chloride of sodium and urea. 

Various abnormalities of the cerebrum may be present from arrests of 
development, and sometimes traces of old disease can be discovered, such 
as patches of sclerosis resulting from past haemorrhage or inflammation. 
The cerebral substance generally may be of normal consistence, or anaemic, 
or oedematous. Congenital hydrocephalus is often combined with other 
arrests of development, such as cardiac malformations, spina bifida, hare- 
lip, etc. 

In acquired hydrocephalus the changes above described stop short of 
the extreme degree often reached when the disease is congenital. The 
ventricles are still dilated, but to a less extent. They contain several 
ounces of fluid (six, eight, ten, or twelve), usually limpid and clear. The 
ependyma of the ventricles is thickened and often dotted over with fine 
nodules, especially upon the optic thalami, the fornix, and the stria cornea. 
The choroid plexus is congested, and the brain-substance may be denser or 
tougher than natural. 

If the fluid is in the arachnoid space it is spread more or less over the 
surface of the brain. The brain is often oedematous, and its consistence 
is reduced. In extreme cases it may be converted into a white pulp (hy- 
drocephalic softening). 

Symptoms. — Many cases of congenital hydrocephalus which reach the 
full period of gestation die during delivery or shortly afterwards. Others 
survive for a variable period, but they die in the majority of cases before 
the end of the second year. In rarer instances the patient may live for 
five or ten years, or longer, and it is said may even reach extreme old age. 

At birth the size of the head is not always remarkable. The appear- 
ance of the new-born infant may be natural, and no cranial enlargement 
may be observed until after the lapse of some weeks. Most cases of hy- 
drocephalus present both physical and mental peculiarities. The head of 
the child becomes very large, but his general development is strikingly 
backward. The increase in size of the skull is gradual and progressive, 
and in some cases the volume of the head becomes enormous. The pecu- 
liar shape of the skull and the strange contrast between the dimensions of 
the cranium and the little jrinched and pointed face beneath it is very 
striking and characteristic. In a well-marked case the large globular 
head, greatly expanded at the sides and flattened at the crown, combined 
with the small face, if represented merely in outline upon paper, would 
give the impression of a large oriental turban placed uj)on the head of a 
child of ordinary size. The skin over the cranium is thin and seems 
stretched ; the veins are full ; the hair is scattered and meagre. On placing 
the hand upon the head the large fontanelles, the widely opened sutures, 
and the thin, yielding bones convey almost the impression of a tense bag 
of fluid. Often fluctuation can be detected, and the soft parts may have 
a slight pulsation, rhythmical with the breathing, falling in during inspi- 
ration and dilating again as the breath is expired. The face is thin, the 
cheeks are often hollow, and the chin is small and pointed. The eyeballs 
are forced forwards by the flattening of the roofs of their sockets, and at 
the same time the eyebrows and eyelids are drawn upwards by the tension 
of the skin. Consequently the eyes look prominent. They appear also 
to be directed downwards, for there is a rim of white above the cornea 
from uncovering of the sclerotic, while the lower half of the pupil is cov- 
ered by the lower eyelid. This large head is necessarily a heavy one, so 
that the child has a difficulty in supporting it. As the general nutrition 



CHEONIC HYDEOCEPHALUS— SYMPTOMS. 343 

is imperfect, and the muscular development of the patient far below a 
normal standard, the difficulty is often great. The child may endeavour to 
support the head with his hand, but often he has to abandon the attempt 
to keep himself upright, and is forced to rest his head on a pillow or on 
his mother's lap. The weight of the head is one reason why these chil- 
dren are slow in learning to walk. Another cause is the imperfect state of 
nutrition of the body generally. Although the child as a rule takes food 
greedily and appears to digest it, he does not thrive. His head gets bigger 
and bigger, but the muscles of the trunk and limbs remain feeble, flabby, 
and thin, and seem to derive no benefit from his copious meals. 

The intelligence of hydrocephalic patients varies greatly in different 
cases. Sometimes it appears to be unaffected, and mental development 
continues in normal progression. As a rule, however, the child is back- 
ward. He is slow to take notice, apathetic, and dull at an age when other 
infants can be easily amused. The time for walking arrives, but he makes 
no effort to "feel his feet," and if held upon the ground allows his limbs 
to double up helplessly underneath his body. When at last he learns to 
walk his gait is tottering and uncertain. Tins backwardness in locomo- 
tion appears to be partially due in many cases to want of intelligence, but 
the general muscular weakness and^the weight of the head contribute, no 
doubt, greatly to the deficiency. 

It is very difficult to ascertain the degree of keenness of the senses in 
infants. Hydrocephalic babies are often thought to be deaf, but this is 
probably due in many cases to want of attention. The sight is often im- 
paired, and — as in many other cerebral diseases of infants — the child may 
not take notice of faces and objects because he sees them indistinctly. 
Dr. Clifford Allbutt believes ischsemia papillae to be the earliest change, 
but states that soon the disks and retinas become wholly disorganised and 
the optic nerve is atrophied from pressure. The ophthalmoscope shows the 
disks atrophied, their outlines blurred or lost, the vessels distorted or 
closed, and the retina maculated with patches and streaks of a brownish 
or whitish colour from old haemorrhages, exudations, and fatty degener- 
ations. Nystagmus is a common symptom in these cases, and there is 
often a convergent squint. 

Nervous symptoms are seldom absent. The patient maybe distressed 
by attacks of laryngismus stridulus, and Dr. West has observed spasmodic 
dyspnoea. Convulsions are not rare, and sometimes recur at short intervals. 
So also partial paralyses, contractions, and automatic movements may be 
features of the disease. There may be also diminished sensibility of the 
skin, and occasionally the opposite condition — hyperesthesia— has been 
noticed. These children appear to suffer from frequent cephalalgia. The 
pressing of the head into the pillow and the frequent rolling of the head 
from side to side as the infant lies in his cot are almost invariably symp- 
toms of uneasiness within the skull, and these are seldom absent in hydro- 
cephalic cases. Sometimes the head is retracted. 

As an example of an ordinary case of chronic hydrocephalus I may in- 
stance a little girl, aged two years and a half, who was admitted under my 
care into the East London Children's Hospital. The child was of small 
size except her head, and weighed eighteen pounds six ounces. The 
head had been noticed to be big from the age of three months, and had 
been constantly growing larger. The patient had been subject to convul- 
sions ever since birth. She could not stand or support her head. The 
skull at the level of the bosses of the temporal bones measured twenty-two 
inches in circumference. The fontanelles were very large and tense, and 



344 DISEASE IN CHILDEEN. 

the sutures were widely open. There was slight retraction of the head, 
with some rigidity of the muscles at the back of the neck. The wrists and 
elbows of both upper extremities were kept constantly flexed, and the 
thumbs were inverted. There were no actual convulsions, but the child 
often twitched all over. She was very dull and stupid, but could be made 
to look round by calling to her. She was not blind ; but there was nys- 
tagmus, and squint was often noticed. Her temperature was normal. 

The duration of the disease varies. Many patients die during the first 
year of life, and comparatively few survive to the second. Still death does 
not always take place so early. Sometimes a sudden arrest occurs in the 
disease. The head then ceases to enlarge, ossification goes on slowly, and 
general nutrition improves. In these cases it is often long before bony 
union is completed in the skull. In the case of Cardinal, recorded by 
Dr. Bright, who lived with an enormous skull to the age of thirty years, 
ossification was not completed until two years before the patient died. 

In acquired hydrocephalus the symptoms are much the same as those 
described in the congenital form, so long as the effusion occurs before 
consolidation of the skull is completed. If, however, it takes place after 
the fontanelle is closed, the symptoms are obscure, for there are no exter- 
nal signs of distention. The child generally becomes dull and heavy. 
There is headache, vertigo, and oftenCn apparent difficulty in supporting 
the head, so that the patient lies about and seems to dislike movement. 
If made to walk, he totters and steps cautiously. Twitching or convulsive 
movements may come on, the pupils get sluggish and dilated, and the 
pulse slow. Then the stupor deepens into coma and the child dies. 

In rare cases the symptoms may be relieved by spontaneous evacuation 
of the fluid. Mr. L. W. Sedgwick has recorded such a case. A little 
boy, two years of age, two of whose brothers had died of the disease, and 
who had always himself had a large head, began to be listless and dull. 
He often complained of headache and wanted to lie down. He slept 
badly at night and often woke up with a scream. After a time his head 
was noticed to be growing larger ; the fontanelle became very wide ; the 
pupils were dilated and sluggish, and there was some insensibility to ex- 
ternal impressions. The respirations, too, became slower and the breathing 
was oppressed, While in this state, the case appearing every day to be 
more hopeless, a sudden change was noticed for the better. The patient be- 
came brighter ; his drowsiness cleared off ; his pupils began again to re- 
spond to light ; and he ceased to complain of his head. This improvement 
coincided with a copious flow of watery fluid from the nose ; and after a 
large quantity of fluid had thus escaped all the unfavourable symptoms 
disappeared. Twelve months afterwards they returned, and increased to 
a degree that seemed to render the child's recovery out of the question ; 
but again they were relieved in a precisely similar manner. A case of the 
same kind is recorded by Mr. Barron in which a large quantity of watery 
fluid mixed with blood was discharged from the nose and mouth. In this 
instance the patient died, and on examination of the skull, a narrow pas- 
sage was found conducting from the cranium to the nose through the eth- 
moid bone. 

Although the disease may become arrested, and in children who survive 
the accumulation of fluid always becomes stationary after a time, the usual 
termination is in death. Such children, with their weakly frames and feeble 
resisting power, fall easy victims to any intercurrent disease ; and, as a rule, 
succumb to an attack of bronchitis, pneumonia, or severe intestinal catarrh, 
even if they do not die from actual interference with cerebral function. 



CHRONIC HYDROCEPHALUS — DIAGNOSIS — TREATMENT. 345 

Diagnosis. — Mere enlargement of the head is no proof in itself of the 
existence of hydrocephalus unless other symptoms of fluid are present. 
In rickets the head is often large, and sometimes this increase in size is 
due to actual hypertrophy of the brain. In syphilis it may be also large 
from extreme thickening of the cranial bones. In both of these cases, 
however, a certain excess of fluid may be effused, although the quantity 
may be insufficient to produce any ill effects from pressure. Still, unless 
actual intra-cranial dropsy be present, we never see the peculiar globular 
shape of the skull which is met with in chronic hydrocephalus. The 
characteristic features of this condition have already been sufficiently de- 
scribed. 

In cases of acquired hydrocephalus, when the collection of fluid takes 
place after closure of the fontanelle, diagnosis is very difficult. The con- 
dition is usually dependent upon a tumour of the brain compressing the 
veins of Galen. It may be suspected when symptoms of gradually iucreas- 
ing pressure upon the brain are noticed, and absence of the more special 
phenomena peculiar to the inflammatory forms of cerebral disease throws 
us back upon this as the most likely cause of the symptoms. The seat of 
the fluid effusion is often difficult to ascertain with any precision, but it 
must be remembered that internal or ventricular hydrocephalus is more 
common than the external variety. Mr. Prescott Hewitt states that the 
flattening of the orbital plates, which forces forwards the eyeballs, occurs 
only in the internal form. If, then, in any case the eyeballs are prominent, 
and we see the lower half of the pupil covered by the lower eyelid, while 
a rim of white is seen above the cornea, we may conclude that the dropsy 
is ventricular. 

Prognosis. — So few children, comparatively, survive the second year 
that the prognosis in intracranial dropsy is always very serious. Congeni- 
tal cases mostly die, and in no instance can we give a favourable opinion 
unless evidences of arrest of the disease have become unmistakable. Cer- 
tainly in no case can we venture to hope for so favourable a termination as 
a spontaneous evacuation of the fluid. Even if the disease become ar- 
rested, the patient remains in most cases with a large unsightly head and 
a more or less blunted intelligence. Convulsions, twitchings, retraction of 
the head, and other signs of cerebral irritation are unfavourable symptoms. 
So, also, are continued wasting and looseness of the bowels. If the patient 
is weak, any intercurrent disease generally proves fatal. 

Treatment. — Cases of chronic hydrocephalus are the despair of the physi- 
cian. He can do little more than attend to the general health of the child, 
regulate his bowels, and exercise a judicious supervision over his dietary. 
As regards arresting the disease, or causing absorption of fluid already ac- 
cumulated, treatment appears to be of slight value. I have thought that 
the persevering employment of perchloride of mercury has been of service, 
for I have found arrest of the disease to occur in one or two instances 
while the drug was being given, but the same treatment has failed in so 
many other cases that the more favourable result was in all probability a 
mere coincidence. I have never seen special benefit derived from diuretics 
or tonics, blisters, strapping, or artificial evacuation of the fluid. I have 
several times punctured the fontanelle half an inch to one side of the 
median line, and after withdrawing a quantity of fluid have strapped up 
the head tightly with carefully applied strips of adhesive plaster. But 
although the patient appeared uninjured by the operation the fluid always 
quickly re-accumulated. If the skull is enlarging rapidly, I believe the 
strapping treatment to be decidedly injurious. 



CHAPTER XIII. 

OTITIS AND ITS CONSEQUENCES. 

(Purulent Meningitis ; Thrombosis of the Cerebral Sinuses ; Encephalitis.) 

Otitis in the child is a common disease, and may lead to very serious con- 
sequences on account of the facility with which inflammation can extend 
from the tympanic cavity to the interior of the skull. During the first few 
years of life the mastoid process is in a rudimentary state. In the young 
child, therefore, the mastoid cells are limited to the horizontal portion 
which lies behind the tympanic cavity, and above and slightly posterior to 
the auditory meatus. It is only at a later period that they extend down- 
wards and backwards to form the hollow of the mastoid process. These 
cells communicate with the tympanum, and share in any catarrhal process 
of which that cavity may be the seat. The tympanum itself is separated 
from the interior of the skull by a thin layer of bone, which is often a mere 
translucent shell. This, according to Toynbee, may even be deficient in 
places, so that the mucous lining of the tympanum is sometimes here and 
there in actual contact with the dura mater covering the temporal bone. 
It is then easy to understand how, without any disorganisation of the bony 
layer itself, inflammation may extend from the tympanic cavity to the in- 
terior of the cranium, and give rise to serious disease of the brain and its 
membranes. 

The inflammation may spread from the ear to the skull-cavity through 
either the roof of the tympanum or that of the mastoid cells. It may also 
pass through the upper wall of the external auditory canal, or be conveyed 
inwards by means of the internal auditory meatus, which is lined by a 
prolongation of the brain membranes. The petrous bone may or may not 
participate in the disease. Sometimes it becomes carious. In other cases 
serious disease of the brain and its membranes may be set up, although 
the bony layer separating the ear cavities from the interior of the cranium 
seems in no way affected by the inflammation around it. 

Causation^ — In childhood there appears to be a special tendency to 
catarrh of the mucous membrane lining the middle ear. Von Troltsch 
has commented upon the frequency with which in young persons this con- 
dition is discovered after death, without any symptom of the derangement 
having been observed during the life of the patient. The tendency is 
heightened by the scrofulous diathesis, and in the subjects of this consti- 
tutional state the catarrh has a special proneness to become a serious sup- 
puration. Diseases which have an influence in provoking the manifesta- 
tions of the scrofulous cachexia are very apt to be followed by suppurative 
otitis, as scarlatina, measles, and small-pox. Besides these causes, cold or 
slight injuries to the ear may set up the same condition, and sometimes 
the tympanum becomes affected as a consequence of similar disease in 
parts around. Thus inflammation may spread to the middle ear from 



OTITIS — CAUSATION — MORBID ANATOMY. 347 

the external auditory meatus or from the pharynx. Dr. Knapp, of New 
York, states that in the majority of cases the occurrence of suppurative 
catarrh of the middle ear is due to cold, which affects first the naso-pha- 
ryngeal cavity, and then spreads up the Eustachian tube. In 8.78 per 
cent, of his cases he attributes the immediate cause of the otitis to sea 
bathing ; in 7.74 per cent, to scarlatina. The extension of the inflamma- 
tion further inwards to the skull-cavity may be determined by any agency 
capable of setting up acute inflammation in the ear. Cold is a frequent 
cause of this disaster, and blows upon the head may produce the same 
result. It is an occasional complication of dentition (see page 560). 

Morbid Anatomy. — When the mucous membrane lining the tympanum 
becomes acutely inflamed, it is of a deep red colour, and its vessels are full 
and distended. In the chronic stage the mucous membrane becomes 
thickened and pours out a copious purulent secretion which usually per- 
forates the tympanic membrane and issues from the external meatus as a 
yellowish-white discharge. A chronic otitis may continue for months, or 
even years, without producing much inconvenience. But sometimes the 
inflammation extends to the bony wall, which becomes carious and soft- 
ened ; or the inflammation suddenly assumes an acute character. In either 
case violent symptoms may be all at once noticed from implication of the 
brain and its membranes. The consequences of spreading of the inflam- 
mation to the skull cavity are the occurrence of purulent meningitis, and 
of encephalitis with abscess of the brain. 

In purulent meningitis there may be inflammation and thickening of 
the dura mater (pachymeningitis), and this membrane may be separated 
from the petrous bone. Often suppuration takes place between it and the 
bone ; the membrane is perforated, and pus is effused into the cavity of 
the arachnoid. If disease of the petrous bone is one of the consequences 
of the otitis, thrombosis of the cerebral sinuses may occur, and pyaemia 
may be produced. In all cases where the dura mater is inflamed, phlebi- 
tis and thrombosis of the cranial sinuses are frequent consequences. The 
coagulation of the blood and arrest of the circulation in the venous chan- 
nels is due to narrowing of the calibre of the sinus either b}^ pressure 
upon it of inflammatory products or by thickening of its walls owing to 
inflammatory infiltrations and abscesses. As a rule the lining membrane 
of the sinus is smooth, but it sometimes becomes roughened and dull- 
looking. The clot which forms the thrombus is fibrinous, and contains but 
few red blood corpuscles. It is therefore whitish-yellow in colour, or slightly 
gelatinous-looking, from the number of white corpuscles. It may lie free 
in the sinus or form loose adhesions to the walls. These decolourised 
clots are sometimes very extensive, and may reach from the lateral sinus 
downwards to the vena cava. If the child live long enough, the thrombus 
may soften in the centre, and the disintegrated fibrine may present a pus- 
like appearance to the eye. 

The pia mater is almost always affected. Its vessels become dilated 
and filled with blood ; small patches of ecchymosis are scattered about ; 
and a yellowish or greenish exudation is poured into the subarachnoid tis- 
sue. This exudation may be solid like an ordinary false membrane, but 
is often distinctly purulent. It varies greatly in amount. The cortex of 
the brain, as might be expected from the intimate connection which exists 
between its vessels and those of the investing pia mater, usually shares in 
the inflammatory condition, and becomes injected and softened. 

Encephalitis usually occurs in patches. The vessels are dilated and 
congested ; there is effusion into the tissue around them which becomes 



348 DISEASE m CHILDREN. 

swollen, red, and soft (acute red softening), and can be washed away by a 
stream of water. Surrounding the inflamed patch the cerebral tissue is 
congested and cedematous, and of a yellowish colour. As the process 
goes on the colour of the diseased spot changes from red to greenish ; its 
substance gets softer and softer, and the central part breaks down into a 
yellow or green purulent matter. The wall of the abscess thus formed 
consists of brain-substance more or less softened. The seat of the abscess 
in cases of otitis is in the adjacent part of the middle or posterior lobe of 
the cerebrum, or in the cerebellum. As a consequence of the abscess and 
inflammation of the brain-substance at the spot, there is enlargement of 
the affected part of the brain, its convolutions are flattened, and its sulci 
partly obliterated. 

To produce these secondary results in the skull cavity it is not neces- 
sary that caries of the petrous bone should occur. In many cases the bone 
itself is found intact, the dura mater even may have the appearance of 
health, and a layer of healthy-looking cerebral substance may separate the 
abscess from the surface of the brain. 

Symptoms. — Acute otitis may be present without any symptoms indi- 
cating the existence of the inflammation. Usually, however, as the puru- 
lent secretion accumulates in the cavity of the tympanum, especially if the 
tympanic membrane shares in the inflammation, there is severe pain in the 
ear and side of the head, and pressure on or around the ear increases the 
suffering. In babies earache is a common affliction, and may even be a 
cause of convulsions. The child cries incessantly with a peculiar shrill 
scream, and refuses to be comforted. He burrows his head in his pillow, 
or rests it against his mother's shoulder, often lifts his hand to his head, 
and refuses the bottle or the breast. If the pain cease or subside for a 
time, he falls asleep, but usually wakes up again after a short interval 
screaming loudly, and continues to cry again incessantly as before. After 
some hours of this agony the tympanic membrane gives way, a discharge 
of pus issues from the meatus, and the cry at once ceases. Examination 
of the ear in these cases seldom affords much information, although the 
passage sometimes looks red and inflamed. 

When a chronic otitis exists, there is a more or less copious purulent 
discharge from the ear, the tympanic membrane is destroyed, and the 
sense of hearing is blunted. So long as no more pus is formed than can 
pass readily away, no other ill effects are observed, and the absence of the 
tympanic membrane usually allows of free escape of the matter exuded. 
Sometimes, however, an accumulation of pus takes place in the mastoid 
cells, and ill consequences follow. The chief danger in these cases is the 
occurrence of a fresh acute attack. The otorrhcea then ceases at once, 
there is an intense pain in the ear and side of the head, and often menin- 
gitis with all its serious consequences ensues. It must be remembered, 
however, that as otitis may exist without giving rise to symptoms, menin- 
gitis occurring as a result of inflammation of the tympanum is not always 
preceded by otorrhcea. Sometimes the symptoms of meningitis precede 
the otorrhcea, and sometimes the otitis is latent throughout. 

In an ordinary case of extension of the inflammation to the meninges 
the sequence of symptoms is as follows : A little child of a few years old 
has a discharge of purulent matter from the ear. This may have followed 
an attack of severe earache, or may have begun without pain and continued 
without discomfort, although the hearing on that side has been noticed to 
be dull. The otorrhcea continues for several months. Occasionally the 
child is feverish and complains of acute pain in the affected ear and side 



OTITIS — PUEULEKT MENINGITIS. 349 

of the head. At the same time the discharge from the meatus ceases to 
flow. After some hours, however, the pain subsides and the running re- 
appears. At length the patient is seized with high fever, and has an attack 
of violent convulsions. After several repetitions of the fits, in the intervals 
of which he seems drowsy and stupid, he sinks into a state of coma and 
dies within the week. This is called the convulsive form — long standing 
otorrhoea ; then, suddenly, fever, convulsions, coma, death. It is the 
shape the disease takes in babies and children under two years of age. 

The fever is high. The temperature rises to between 104° and 105°, 
and undergoes at first little remission in the mornings. The pulse almost 
always intermits more or less completely, and very often falls in frequency, 
sinking to 75 or 80. This, however, is a very variable symptom, and 
sometimes the pulse remains quick throughout. Pain in the affected side 
of the head is seldom absent. The youngest children, in the intervals of 
convulsions, may be noticed to moan and put their hands to their heads. 
Respirations are quickened and may be perfectly regular, although some- 
times we notice sighing respirations, and the breathing towards the end 
may assume the Cheyne-Stokes type. The pupils are generally contracted 
at first, and become dilated later. They are often unequal in size. There 
may be squinting of one or both eyes, and sometimes we note a paralysis 
of the face on the affected side. 

The convulsions are violent, and, for the most part, bilateral. In the 
intervals consciousness is not completely restored., the child is heavy and 
stupefied, taking little notice of persons and things around, although his 
attention can be usually attracted by calling him loudly by name. He is 
very restless, and often keeps one or more of his limbs in constant move- 
ment. Rigidity of the joints may be present, and if there is any accom- 
panying spinal meningitis, the head is firmly retracted on the shoulders 
with rigidity of the muscles of the nucha. The abdomen is seldom 
markedly retracted as in tubercular meningitis, and the characteristic 
doughy feel of the abdominal wall is also usually absent. The child re- 
fuses his bottle, and often can scarcely be made to swallow liquid from a 
spoon. The disease runs its course rapidly. After a day or two the con- 
vulsions become less frequent. The child lies plunged in a deep stupor, 
and after remaining comatose for a variable time, dies without any return 
of consciousness. Sometimes convulsions immediately precede death. 

In certain cases the disease may run an even shorter course, and death 
take place with startling rapidity. 

A little boy, aged twelve months, strong-looking and well nourished, 
was seized with vomiting at 1 a.m. on February 16th, and continued to 
vomit at intervals for twelve hours. He then had several fits, and at 3 p.m. 
was brought to the East London Children's Hospital. He was seen by Mr. 
Scott Battams, the house surgeon, who noted that all the limbs were con- 
vulsed and the pupils were dilated. When the fits ceased the child still 
continued insensible ; there was nystagmus ; the pupils were equal and di- 
lated, and acted well with light ; the conjunctivae were insensitive ; there 
was no squint ; the cerebral flush was fairly marked ; the limbs were flaccid. 

At 8 p.m. the child was still insensible. He had had no more fits ; 
pulse, 150, with occasional intermissions ; respirations, 40 ; temperature, 
103° ; pupils equal, and still acted with light. 

All through the night the child remained insensible. There was no 
vomiting, and the convulsions were not repeated. No twitching was 
noticed, and the head was not retracted. He died at 8 a.m. Before death 
the temperature was 104°. 



350 DISEASE IN CHILDREN. 

On examination of the brain, the whole convexity was found coated 
with yellow lymph which had extended to the under surface of the frontal 
lobes, and had glued the anterior and middle lobes to one another. There 
was no flattening of the convolutions ; no excess of fluid in the ventricles ; 
no exudation in the optic space ; and no inflammation of the membranes 
at the base of the brain. No gray granulations could be seen ; the brain 
was firm, and seemed perfectly healthy ; the cerebral sinuses contained 
semifluid dark blood. 

In this case there was slight discharge from the ears, but without of- 
fensive smell. It is doubtful if this had any part in producing the menin- 
gitis, for the dura mater covering the petrous bones had a healthy appear- 
ance. Nothing in the history of the child could be discovered to account 
for the illness, for although he had had a cough for a fortnight, and had 
whooped during the last two days, this could not be looked upon as 
a determining cause of the inflammation. It may be remarked that 
the symptoms above described resemble exactly those often present in 
cases of meningeal haemorrhage in the young child, with the excep- 
tion that in this case the temperature was elevated. A raised tempera- 
ture, present in meningitis and absent in haemorrhage, appears to be 
the single important symptom by which the two diseases may be dis- 
tinguished. 

Above the age of two years it is usual for the meningitis to assume a 
different shape. Convulsions are a less prominent symptom ; instead we 
find a more or less violent delirium. Hence Rilliet — to whose labours all 
descriptions of meningitis in the child are so much indebted — has called it 
the " phrenitic " form. It is of longer duration than the convulsive variety, 
and resembles more meningitis as that disease occurs in the adult. The 
child complains of severe headache, is agitated and restless, and very 
rapidly becomes delirious. The delirium is noisy. The child raves about 
the pain in his head. His eyes are red and wild-looking, his pupils con- 
tracted and often unequal in size. The pulse is quick and irregular, and 
may be completely intermittent. His temperature is high, marking 104° 
or 105°, as in the preceding variety ; and his breathing is rapid, although 
usually regular. After some days the delirium becomes less violent. The 
child has intervals of quiet in which he appears to be unconscious. He 
lies with his eyelids half open and his eyes turned upwards, moaning oc- 
casionally ; the muscles of his face twitch ; there is trismus or grinding of 
teeth ; and his head is often retracted upon his shoulders. As the disease 
progresses the coma becomes more constant, but at first a touch may ex- 
cite violent delirious struggles, for there seems to be general hypersesthe- 
sia making the slightest pressure painful. The pupils dilate, and are in- 
sensible to light ; there is often oscillation of the globe of the eye and 
squinting. The pulse becomes very frequent, and the respirations are of 
the Cheyne-Stokes type. There may be rigidity of the joints. The coma 
continues profound, and the patient gradually sinks and dies. Usually 
there is profuse sweating before death, although the temperature continues 
high ; and the disease may terminate in a fit of convulsions. 

Sometimes the temperature falls considerably before death. At other 
times it rises rapidly to 108°, or even higher. The duration of the phreni- 
tic form of the disease varies ; its course may be rapid like that of the con- 
vulsive variety, but sometimes it is prolonged to three, four, or more weeks. 
In these slower cases the illness often assumes a subacute type, with only 
slight elevations of temperature ; but at any time the heat of the body may 
undergo a sudden and apparently causeless increase. 



OTITIS — THKOMBOSIS — ENCEPHALITIS. 351 

In many cases inflammation of the dura mater is accompanied by 
thrombosis of the cerebral sinuses. The symptoms, however, of this con- 
dition are masked by those of the accompanying meningitis ; and its ex- 
istence, therefore, can seldom be more than suspected. According to 
Gerhardt, we may sometimes detect on the affected side comparative 
emptiness of the jugular vein, which is no longer filled with blood from 
the obstructed sinus ; but this is a symptom the existence of which it 
must be difficult to ascertain. In ordinary cases the occurrence of shiver- 
ing, or great variations in the temperature, with signs of metastatic 
deposits in the lungs (sudden dyspnoea, cough, and perhaps scattered zones 
of crepitation about the chest or back) would point to the probable occur- 
rence of cerebral phlebitis. 

When meningitis occurs as a consequence of other causes than otitis, 
the symptoms are as described, with the addition, in most cases, of a pre- 
Hminary stage in which the child complains, if old enough ; of headache, 
gradually increasing in intensity. He is feverish, vomits, is very restless, 
and his ideas are confused. The course of the disease is therefore rather 
longer than in the form described above. 

Inflammation of the brain (encephalitis) is more frequently than the 
preceding a consequence of otitis. Indeed, it has been estimated that fully 
half of the cases of abscess of the brain are due to inflammation originating 
in the middle or internal ear. The inflammation is limited to certain 
spots, being usually confined to the cerebrum in the immediate neigh- 
bourhood of the petrous bone. Sometimes, however, it is found in children, 
as it is commonly in the adult, in the cerebellum. 

The symptoms are often obscured by meningitis, which may exist at 
the same time ; and there may be thrombosis of the cranial sinuses. 

The disease begins with pain in the head, which is indicated in the 
young child by repeated screaming and frequent movement of the hand to 
the head. The child seems drowsy, and behaves as if only half awake. He 
takes food unwillingly or refuses it altogether. The bowels are generally 
confined, and there is usually vomiting. The temperature seldom rises 
above 102°. The pulse is generally slow (70 to 80), and the pupils are 
contracted. The drowsiness soon deepens into stupor, and there is rigid- 
ity of the joints, usually limited to one side, with i^rhaps paresis or 
paralysis of the limbs. Much depends upon the seat of the abscess, and 
whether it affects the centres of special sense or interferes with the con- 
duction of motor influences. Thus there may be incomplete hemiplegia 
from compression of the fibres of the internal capsule ; paralysis of the 
third nerve from pressure on the cerebral peduncle ; or paralysis of the 
facial nerve. The loss of power is almost invariably limited to one side of 
the body. Convulsions may occur ; there are frequent tvdtchings of the 
facial muscles, and the child grinds his teeth and makes movements with 
his mouth as if chewing. The stupor is not constant. At first the child 
can be roused by being spoken to loudly ; and occasionally the mind be- 
comes clearer after a time. The child will often begin again to answer 
questions, and may even recognise his friends. The respirations are quick- 
ened and very irregular ; the pulse, after the first few days, increases in 
rapidity, and often becomes intermittent. In acute cases the stupor soon 
becomes more profound, and deepens into a coma in which the child dies. 
Convulsions, if previously present, may cease when the patient becomes 
comatose, or may return before death. The temperature remains moder- 
ately elevated throughout, or falls notably before the fatal termination, or 
rises to a high level during the last few hours of life. 



352 DISEASE IN CHILDPwEN. 

A rickety little boy, aged two years, was admitted into the East Lon- 
don Children's Hospital with the symptoms of severe pulmonary catarrh. 
For some months the child had been subjpct to otorrhcea, but there was 
no history of earache. He went on well at first ; the cough improved and 
his chest seemed greatly relieved, when, on December 7th, his temperature 
rose to 102°, and there was a copious discharge of pus from the left ear. 
The discharge continued through the week, but the child seemed to suffer 
little inconvenience from the state of his ear. He was lively, took his 
food with appetite, and his temperature, which for a few days had been 
high, again sank to 99°. 

On December 13th a change was noticed. The child screamed fre- 
quently and seemed indifferent to his food. His temperature that evening 
was only 99°. On the morning of the 14th the temperature was still 99°, 
but the pulse, which had been always considerably over 100, was found to 
have fallen to 80. The child was drowsy and could not be thoroughly 
roused. He lay on his right side with a puffy-looking flushed face, grind- 
ing his teeth and making other movements with his jaws. The pupils 
were equal, slightly contracted, and sluggish ; occasionally there was a 
slight squint. Some rigidity was noticed of the right knee and elbow 
joints. The child took no notice of questions and refused food. At 6 p.m. 
the temperature was 100° ; pulse, 96 ; respirations, 34 ; and in the evening 
the stupor deepened into coma. 

For the next forty-eight hours the child's state continued much the 
same. He was completely insensible, and squinted outwards with the 
right eye. During this time his temperature was 101°-101.4° ; pulse, 120- 
130 ; respiration, 21-48, and very irregular. The abdomen was slightly 
retracted ; the bowels were confined, and he vomited once. 

On December 16th the bowels had been moved by aperients, and there 
was some approach to consciousness. The child resisted the feeding cup, 
and in the evening seemed to recognise the nurse. He was heard to say 
" no " repeatedly when offered drink. He could move both his legs. The 
temperature was 100°-101°. 

On December 17th the stupor was even less, although the patient re- 
mained very drowsy ; he turned his head when called loudly by name, and 
answered when asked to drink. There was no flushing of the face, nor any 
redness when pressure was made on the skin. Temperature, 100°-101.6° ; 
pulse, 156 ; respirations, 38. On the 18th the child had two fits. These 
were followed by no rigidity of the joints ; but the patient lay in a semi-coma- 
tose condition, although it was still possible to rouse him by loud calling. 
From that time he gradually sank, and died on the afternoon of the follow- 
ing day. The temperature shortly before death was 101°. On examina- 
tion of the body, the petrous part of the temporal bone was found de- 
nuded of dura mater at one spot, and the membrane around was much in- 
flamed. An abscess was discovered in the adjacent cerebellum filled with 
offensive pus, and there was excess of fluid in the lateral ventricles. 

The course of encephalitis is usually rapid. It may last only five or six 
days, or may be prolonged to two or three weeks. Sometimes after a time 
the acute symptoms disappear, consciousness is recovered, and the child's 
health may appear to be restored. It is even said that such children may 
grow up to adult age, the abscess having become encysted and ceasing to 
be a source of irritation. 

Diagnosis. — Otitis should be suspected in all cases where a young child 
cries incessantly without any symptoms being detected — such as drawing 
up of the legs, tension of the abdominal wall, unhealthy evacuations, etc.— 



OTITIS — DIAGNOSIS. 353 

to draw attention to the belly. Abdominal pain is intermittent, and the 
cries cease when the uneasiness subsides. Earache is constant, and until 
relief is obtained by the discharge of pus from the meatus the child cries 
with a persistence which is very characteristic. 

When purulent meningitis occurs, the onset of violent convulsions, with 
high fever, following urjon sudden cessation of discharge from the ear, are 
very suspicious ; and when we remark that in the intervals of the fits the 
child remains drowsy and stupid, refuses food, and takes no notice of ac- 
customed faces ; that he is restless, contracts his brows, and constantly 
moves his hand to his he"ad, we can speak with some confidence as to the 
nature of the case. In reflex convulsions the mind is clear between the 
attacks. Drowsiness or stuj3or with recurring convulsive movements is 
very characteristic of a cerebral origin. An alteration in the pulse adds 
a new and important feature to the case. A pulse of 80 in a young child 
is a slow pulse. If the child be feverish, the contrast between the bodily 
heat and the comparative infrequency of the arterial pulsations is still more 
striking. Therefore if to the preceding symptoms we add a slow and per- 
haps intermitting pulse, our suspicions are sufficiently confirmed. 

Fevers or inflammatory diseases in the young child may begin with the 
combination of pyrexia and convulsions. In the case of the exanthemata 
we should find some of the early symptoms of the eruptive fever ; and 
the convulsive movements themselves are few and not violent. There 
is little restlessness, and between the attacks the child takes notice and 
recognises his friends. In the case of malignant scarlatina, beginning with 
convulsions and delirium, there is little headache, and the eruption appears 
within twenty-four hours of the first symptoms of the fever. 

Pneumonia in the child not unfrequently begins with convulsions, and 
there is high pyrexia ; but the absence of stupor and of headache, the ac- 
tion of the nares, the greater rapidity of the breathing, and the perverted 
pulse-respiration ratio would serve to exclude meningitis although a physi- 
cal examination of the chest might reveal no signs of disease. In the so- 
called " cerebral pneumonia," where there is delirium and headache, with 
stupor and high fever, the nature of the disease may be often detected 
early by an examination of the chest. Sometimes, however, physical signs 
are slow to appear, and in such a case we must wait before pronouncing 
an opinion. Usually the head symptoms of cerebral pneumonia are not 
violent, but assume more the characters of tubercular meningitis than of 
the simple form of the disease. The distinction between these two varie- 
ties of meningitis will be considered elsewhere (see Tubercular Meningitis). 

From uremia and the various forms of cranial disease unaccompanied 
by pyrexia, the high temperature which is one of the characteristic features 
of simple meningitis will form a sufficient distinguishing mark. 

In the case of encephalitis, drowsiness with convulsions or rigidity of 
joints, or both, followed by coma and hemiplegia — the symptoms occurring 
in a child the subject of chronic otorrhcea, or following upon an attack of 
severe earache, — sufficiently reveal the nature of the disease. When there 
is no paralysis it is difficult, perhaps impossible, to distinguish inflamma- 
tion of the substance of the brain from inflammation merely of its mem- 
branes, and a certain amount of meningitis usually accompanies the en- 
cephalitis. 

Thrombosis of the cerebral sinuses can seldom be more than suspected. 

If the dura mater be inflamed, it is reasonable to suppose that the sinuses 

at the seat of disease are also implicated. If in a case where the cerebral 

symptoms have evidently followed upon a long standing otorrhcea we can 

23 



354 DISEASE IN CHILDREN. 

detect deficient filling of the jugular vein on the affected side, or can dis- 
cern signs of pyaemia — rigors, or rapid variations of temperature, with 
evidence of metastatic deposits in the lungs or other organs — we may con- 
clude that thrombosis in the sinuses has probably occurred. 

Prognosis. — Otitis can usually be cured by suitable treatment, and- if, 
while the discharge continues, proper measures be taken to prevent the 
collection of purulent matter in the tympanic cavity or mastoid cells, there 
is no reason to apprehend any ill results from the state of the ear. 

If extension of the inflammation take place to the skull cavity, the worst 
consequences may be anticipated. The patient does not, indeed, always 
die, but the proportion of recoveries is very small. In encephalitis it is 
common for the stupor to clear away more or less completely for a time, 
and therefore false hopes should not be raised by the patient's apparent 
amendment ; and the friends should be warned that such signs of im- 
provement are seldom to be trusted. 

Treatment.- — When otitis occurs, it is important to remove pus early 
from the interior of the tympanum. This is done by inflating the Eusta- 
chian tube by means of Politzer's bag. The operation is easily performed 
upon children, as it is not necessary that they should swallow. All that is 
required is to send a forcible blast of air through their closed nostrils. If 
the purulent contents are not removed by this means the tympanum must 
be punctured. When a discharge appears from the meatus, the passage 
should be syringed several times daily with warm water. If any uneasiness 
appears to be felt in the ear, counter-irritation with tincture of iodine may 
be employed behind the pinna. 

A chronic otorrhcea should be stopped as quickly as possible. Any 
mild astringent injection may be employed ; but care should be taken 
thoroughly to cleanse out the passage with warm water before using the 
astringent lotion. In obstinate cases the use, several times daily, of an ap- 
plication composed of sulphate of zinc and borax, ten grains of each, and 
one drachm of glycerine, to the ounce of water, will often arrest the discharge 
very quickly. Glycerine of tannin diluted in the proportion of one drachm 
to the ounce of water, used frequently, is often of service. Sometimes the 
injection, once daily, of a solution of nitrate of silver (gr. x. to the oz.) 
will hasten the cure. In cases of long-standing otorrhcea, when the mem- 
brane of the tympanum is destroyed, the child should w T ear small pledglets 
of cotton wool in the ear, except in very warm weather, as a fresh catarrh 
is easily excited by cold and damp. 

When meningitis occurs, the room should be kept in a half light ; free 
ventilation and perfect quiet should be insisted upon ; and the thermometer 
must be watched that the temperature of the room does not rise above 60°. 
The feet must be kept warm and the head cool. It is advisable to remove 
the hair, and keep the shaven scalp constantly covered with an ice-bag. 
The bowels must be opened freely by aperients, such as calomel and 
jalap. Opinions differ as to the value of morphia in these cases. Morphia, 
even if it produces no impression upon the inflammation itself, can scarcely 
be injurious. Its use has at any rate this advantage, that when the child is 
ke}3t under its influence the more violent symptoms are moderated, and 
much pain is saved to the friends by the apparent relief thus extended to 
the patient's sufferings. Counter-irritation, although often advocated, is of 
little value ; and the old plan of leeching behind the ears has never seemed 
to me to be followed by any improvement. Our great trust should be 
placed in the constant application of cold to the head, in perfect quiet, and 
in free purgation. Encephalitis is to be treated on similar principles. 



CHAPTER XIV. 

TUBERCULAR MENINGITIS. 

A basic meningitis induced by tuberculosis of the pia mater is undeni- 
ably the commonest form of intra-cranial disease to be met with in the 
child. The symptoms to which this variety of meningitis gives rise are 
sufficiently characteristic to merit a separate description ; for the seat of 
the inflammation, the insidious beginning of the illness, and its well-de- 
fined course are very different from what we find in simple inflammation 
of the meninges, and make the affection for all practical purposes a differ- 
ent disease. 

Infants and children of all ages are subject to tubercular meningitis. 
It is little less common in infants than it is in older children ; but in the 
former the disease invariably occurs in the course of an attack of general 
tuberculosis. It is then called " secondary," for its symptoms, being pre- 
ceded by others arising from inflammatory affections of various organs also 
dependent upon the diathetic state, are completely masked in their earlier 
stages, and only reveal themselves as the more violent phenomena which 
mark the closing period of the illness. After the age of infancy the dis- 
ease usually assumes the primary form, for although other organs may be 
the seat of tubercle, the symptoms first noticed are those arising from the 
brain, and these retain their prominence throughout the course of the 
attack. 

Causation. — As a form of acute tuberculosis, tubercular meningitis is 
dependent upon the same predisposing causes as those which give rise to 
the diathetic condition. It is worthy of remark that in families in which 
the tubercular diathesis exists, not only the tendency to tubercular forma- 
tion is handed down, but often, also, a proneness to the particular shape 
the disease is to assume. This is especially the case with regard to the 
meningeal form of the malady. It is not uncommon to hear of several 
children of the same family being carried off by tubercular meningitis ; 
and in doubtful cases the fact that a previous child has fallen a victim to 
the intra-cranial inflammation becomes an important aid in arriving at a 
decision. 

Although children who become the subjects of this disease are often 
weakly and delicate-looking, with a marked tubercular family history, this 
is not always the case. It is not uncommon to see the disease break out 
in children who are stout and vigorous, and who certainly differ widely 
in aspect from the delicately formed and frail-looking type which is con- 
sidered characteristic of the tubercular diathesis. It is possible that infec- 
tion of the system by softening cheesy matter may induce the disorder in 
a child free from any constitutional tendency to this form of illness ; but 
in most cases, however unlikely a subject the child may appear to be, care- 
ful inquiry will discover evidences of " consumptive " tendency in collateral 
branches of the family, if not in the direct line from which the child has 



356 DISEASE IN CHILDPwEN. 

descended. The disease is common in all ranks of life ; but as poverty 
(which too often implies reckless indifference to insanitary agencies, or 
helpless submission to them, even more, perhaps, than actual privation of 
food) may help to determine the outbreak, the affection is especially com- 
mon amongst the poor. ^ 

Of the exciting causes, possibly any injury or -shock to the head, such 
as blows or exposure, may help to induce the illness. Over-excitement of 
the mind, whether from study or amusement, may not improbably have 
the same effect. It has been denied that pressing sensitive children for- 
wards in their learning can act injuriously in this direction. I am, how- 
ever, strongly of opinion that such heedless expedition is very hurtful to 
the child, and has often determined the occurrence of the meningeal 
inflammation in subjects predisposed to tubercle. 

Morbid Anatomy. — The starting-point of the disease is the development 
on the pia mater of numerous gray granulations as a result of the consti- 
tutional state. These gray nodules are found especially on that part of 
the membrane which covers the base of the cerebrum. On the pia mater 
of the cerebellum and convexity of the brain they are much less numerous, 
and indeed appear often to be quite absent from these situations. On 
careful inspection the gray or yellow nodules may be noticed following the 
course of the vessels, especially of their smaller branches. They chiefly 
congregate in and about the Sylvian fissure, and may be often seen also in 
the chiasma of the optic nerve. If very numerous, they may be found 
sprinkled about like a fine glistening dust in these regions and along the 
sides of the hemispheres. The larger granules may be as big as a pin's 
head or even a hempseed. By the microscope the small nodular bodies 
are observed to lie upon the vessels within the perivascular canals, and to 
adhere closely to their coats. On the larger branches they form projec- 
tions on one side of the artery. On the smaller, they may completely 
embrace the vessel. In either case — and this is an essential particular — 
they project inwards as well as outwards, so as to narrow the channel of 
the tube ; and they may even perforate the delicate coats and protrude 
into the interior of the vessel. The granulations are formed by excessive 
proliferation of nuclei from the epithelial lining of the perivascular canals ; 
and the obstruction to the vascular channels which results from this ex- 
cessive accumulation causes thrombosis within the small vessels, great 
impediment to the circulation, severe congestion, and extensive collateral 
fluxions. 

As the meningeal tuberculosis is usually merely a part of a general dis- 
tribution of "tubercle" over the body, the gray granulation is found ako 
in other organs and serous membranes, and has been noticed by Cohnheim 
on the vascular tunic of the retina. 

The vessels of the pia mater are engorged, and the membrane is cloudy 
and often adheres closely to the surface of the brain, so that when torn 
away it brings with it small particles of the cerebral substance. More or 
less copious yellowish or greenish jelly-like exudation is found in the 
meshes of the subarachnoid tissue, often running in streaks along the 
course of the vessels. It is usually confined to the base of the brain. 

An almost invariable feature in these cases is the ventricular effusion. 
This is so constant a phenomenon that it used to be looked upon as con- 
stituting the essence of the disease (hence the name of " acute hydroceph- 
alus," by which the affection was formerly distinguished). The quantity 
is often very considerable. It may distend the ventricles, flatten the con- 
volutions, and even cause rupture of the septum lucidum. In appearance 



TUBERCULAR MENINGITIS — MORBID ANATOMY. 357 

it is clear, or turbid with suspended flocculent particles, or tinged with 
blood. The cerebral substance around the ventricles is softened. The 
softening is attributed by some writers to the effects of mere imbibition and 
maceration. Others ascribe it to inflammation. Dr. Bastian is inclined to 
the opinion that it is often the result of degenerative changes set up by 
the anasarcous condition of the central brain tissue ; and that both the 
ventricular effusion and the softening result from the pressure of the blood 
in the overloaded veins and capillaries, and in some cases, perhaps, from 
actual thrombosis in the veins of Galen. 

Besides this softening of the central parts of the brain, the cortical 
substance is inflamed as well as the pia mater which invests it, and some- 
times spots of softening with capillary haemorrhages have been seen in the 
substance of the corpora striata and the optic thalami. As a rule the brain 
substance is pale and bloodless, and the greater the ventricular effusion the 
whiter and softer the cerebral tissue becomes. 

The above morbid appearances are singularly constant in cases of 
tubercular meningitis. The granulations, the exuded lymph, the vascular 
engorgement, the superficial encephalitis, the ventricular effusion, and the 
white softening of the ventricular walls are almost invariably to be dis- 
covered when death has occurred from this disease. In addition, signs of 
more or less general tuberculosis are also present. These in infants are 
usually well marked, and almost all the other organs and serous membranes 
may be sprinkled over with the gray granulation. In older children, how- 
ever, the meningitis occurs before nutrition has been appreciably impaired, 
and is perhaps itself the earliest indication of the diathesis. In such cases 
the other organs may be healthy, and the granulations scattered over the 
pia mater may be the only morbid formation to be discovered in the body. 
Usually, however, signs of the cachexia are perceptible in other organs, 
and sometimes the granulations are so equally and generally distributed 
that we cannot but wonder at the little interference the constitutional and 
local states had exercised upon the general health of the patient. 

Symptoms. — The onset of the illness is almost always preceded by a pro- 
dromal period of variable duration. This is to be expected in every malady 
where disease of special organs is dependent upon a general diathetic state. 
In all forms of tubercular disease it is a rule which is rarely infringed that 
local symptoms are preceded by phenomena indicating the general disorder 
of nutrition induced by the constitutional cachexia. 

The premonitory symptoms vary in severity, partly according to the 
age of the child, partly according to the previous state of his health, and 
partly according to the intensity of the diathetic influence to which he is 
subject. In young babies, in whom the disease invariably occurs at the 
end of an attack of general tuberculosis, the head symptoms are preceded 
by others indicative of the disease from which he has been suffering. In 
older children, especially in those in whom the diathetic tendency is com- 
paratively feeble, the prodromal period may be short and the symptoms 
trifling. Therefore in different cases we may find marked variety in the 
duration and severity of the symptoms which immediately precede the 
outbreak of the disease. 

Two forms of tubercular meningitis, a primary and a secondary form, 
will be described. 

In primary tubercular meningitis the prodromal period is often short, 
and its symptoms, on account of their indefinite character, may excite little 
attention. The child is thought not to look well, but he makes no com- 
plaint for he suffers no pain. He generally becomes thinner and paler, 



358 DISEASE IN CHILDREN. 

and his appetite is capricious. The loss of flesh is, however, seldom con- 
siderable, and may be only recognised by the use of the weighing scales, 
for no diminution in bulk may be visible to the eye. He is usually listless 
and unwilling to exert himself ; sits and lies about instead of joining in 
the sports of his companions, and if urged to take part in their games, ob- 
jects that he is tired. He is often drowsy, and may be noticed to stop in 
the middle of some childish employment and fall asleep on the floor of the 
room. A change in character is frequently noticed ; and this is a symptom 
so common that it should be always inquired for. The change is usually 
indicated by an increase in his emotional sensibility. If reproved, he 
shows exaggerated distress ; his endearments exhibit an unaccustomed 
warmth ; he readily takes offence, and cries without apparent reason, or 
sits moody and silent in a corner of the room. A certain sluggishness of 
mind is also apparent. An ordinarily bright child becomes stupid over 
his lessons ; he seems drowsy and incapable of fixing his mind upon his 
task. There may be headache, and he may say that the room seems turn- 
ing round. Sometimes there is confusion of sight. The bowels may be 
irregular and costive. The temperature during this period is often 
slightly elevated, and the child looks flushed at night and has hot dry 
hands. In one case which came under my own notice the evening tem- 
perature for the five nights immediately preceding the outbreak was 
100.4°, 98.4°, 98°, 99.6°, and 97.6°. 

The special symptoms of the disease are usually divided into three 
stages ; and when the affection is a primary one this arrangement is justi- 
fied by clinical observation. There is a stage of invasion, in which the in- 
definite symptoms of the prodromal period are suddenly broken in upon 
by the first indications of local mischief ; a stage of irritation, in which there 
is exalted nervous activity ; and, finally, a third stage, which is marked by 
diminution of nervous power and abolition of the functions of life. 

The first symptoms of the stage of invasion are in the large majority 
of cases vomiting and headache, and the bowels which were before costive 
become obstinately constipated. The vomiting is often repeated and 
distressing, and occurs without any reference to taking food. It is, in- 
deed, characteristic of a cerebral origin that retching and vomiting occur 
in the intervals of the meals — towards the end of digestion when the stom- 
ach is nearly empty. The heaving is often excited by raising the child up 
into a sitting position. The matters ejected consist of food and bilious 
or watery fluid. The headache is generally severe. It is referred to the 
front or top of the head, and seems to occur in paroxysms so that the 
patient screams out with pain. The cephalalgia is increased by movement 
or by a bright light, and is accompanied by dizziness so that the child 
staggers in his walk. The expression is distressed, and may be irritable 
or spiteful. The tongue may be clean, but is often thickly furred ; the 
thirst is often great, and appetite is completely lost. The child takes 
early to his bed, from which he never again rises. The abdomen is of nor- 
mal fulness to the eye, but its parietes have a peculiar, soft, doughy feel, 
which is very characteristic, and are easily compressible. Often there is 
marked loss of elasticity of the skin. The pulse is generally rapid and 
regular at this time, but may be slow, and sometimes a fall in the rapidity 
of the pulse is the earliest symptom noticed. Thus, in the child whose 
case has been referred to, a fall in the pulse from 100 to 74 occurred on 
the evening preceding the actual outbreak. The temperature is moder- 
ately elevated (100° to 101°). The breathing is generally irregular, and 
may be unequal and sighing from the first. This is a symptom of great 



TUBERCULAR MENINGITIS — SYMPTOMS. 359 

importance. The child takes several quick breaths in rapid succession. 
Then the respiratory movements cease, and during some seconds the chest 
is motionless. The patient then heaves a deej} sigh and pauses again, or 
his breathing returns for a few minutes to the natural rhythm. Signs of 
great irritability of the nervous system are rare at this early period of the 
illness, although in exceptional cases the disease may be ushered in by a 
convulsive seizure. Still, there are sufficient indications of nervous agita- 
tion. The senses are excessively acute, the pupils are contracted, and light 
is painful to the eyes ; the child is distressed by loud noises ; and hyper- 
esthesia of the skin may be present so that a touch is painful. During 
this stage the urine is scanty and may contain excess of phosphates. 

Of these symptoms the most important are the combination of head- 
ache, vomiting, and confined bowels, with irregular breathing. Even if the 
latter be absent, the occurrence of vomiting and obstinate constipation 
with headache in a child who for some weeks has shown signs of failing 
nutrition is always to be regarded with anxiety. 

In the second stage — the stage of irritation — the symptoms become 
more aggravated. The headache increases in severity, and the child often 
becomes delirious. He lies in his bed with his eyes closed — often squeezed 
together, and his eyebrows contracted — making chewing movements with 
his jaws or grinding his teeth loudly. Sometimes he screams out as if in 
pain. If called, the child usually opens his eyes, but he answers questions 
unwillingly or stares at the speaker angrily and makes no attempt to reply. 
Whether from headache or irritability, the eyebrows often have a scowl 
which gives a peculiarly forbidding expression to the face of the patient. 

The pulse generally falls in frequency at this stage and becomes inter- 
mittent. It varies in rapidity from 60 to 80, and the finger pressing the 
artery finds the rhythm of the pulsations interrupted at irregular intervals 
by the complete omission of one beat. It is important in examining the 
pulse in these cases to seize an opportunity when the child is lying quietly 
and has not recently made a movement ; for a pulse which is slow and ir- 
regular during repose may become quick and regular for a time upon the 
slightest change of position. The temperature is generally lower by a de- 
gree than in the first stage, and may rise no higher than 99°. The respi- 
rations continue irregular as before, and often at this time assume the 
Cheyne-Stokes type. The pupils now become dilated and are often slug- 
gish. Sometimes there is a slight squint, but this is seldom more than a 
passing deviation. Examination by the ophthalmoscope, if it can be man- 
aged, shows a congested state of the retinal vessels and disk, and some- 
times small bodies like gray granulations can be seen projecting from the 
sides of the small retinal arteries. Towards the end of this stage the 
vomiting usually ceases, but the constipation continues, and the child 
shows no desire even for liquids. There is often retention of urine, and the 
motions are passed in the bed after an aperient. The pulse generally 
quickens again, and the temperature rises. The abdomen usually becomes 
markedly retracted, but still remains soft, doughy, and compressible. Be- 
sides, a singular tendency to flushing of the skin is noticed. The cheeks 
suddenly become red, then the flush dies away leaving them apparently 
whiter than before. Slight pressure on the skin, especially of the face, 
abdomen, and front of the thighs, produces a bright redness — the " cere- 
bral flush " of Trousseau, which remains visible for a considerable time. 

The principal symptoms of this stage are the fall in the pulse and tem- 
perature, the apathy and drowsiness of the child, the violent headache, the 
irregularity of breathing, the excavation of the abdomen, the dilatation of 



360 DISEASE IN CHILDREN. 

the pupils, and the passing strabismus. The cerebral flush, unless very vivid, 
is an uncertain symptom, for it is often well marked in cases where there is 
no reason to suspect tubercular inflammation of the cerebral meninges. 

In the third stage the temperature gradually rises again, and towards 
the end may attain a high elevation. The pulse also increases in rapidity 
and becomes regular, but the irregularity of breathing continues. The 
most prominent symptoms of this stage are the increasing coma and the 
occurrence of convulsions and paralysis. The child, who before could be 
roused by loud calling, now makes no sign of response, or if for a mo- 
ment he raises the lids, he closes his eyes again almost immediately. The 
aspect of the child at this period is often very characteristic ; for if, as 
often happens, the disease have been preceded by few signs of ill-health, 
and the patient have retained his plumpness, he presents to the unedu- 
cated eye the appearance of a healthy child in quiet slumber. His cheeks 
are brightly flushed, his countenance perfectly placid, his features rounded 
as in health ; but it will be noticed that the eyelids close imperfectly, and 
that the respirations are very irregular and disturbed by deep sighs and 
long pauses. On raising the eyelids with the finger the pupils are seen 
to be widely dilated, they act sluggishly or not at all, and are often un- 
equal in size. There may be nystagmus or a distinct squint. 

When the coma becomes complete, the flush usually subsides and the 
face becomes very pale. The insensibility is not, however, always pro- 
found. Often it varies in degree, and the child may seem to wake up for 
a time and look round with some intelligence in his glance. Still, it is 
difficult to say whether at these times he is always conscious. In some 
cases the stupor clears off completely for some hours, and the child may 
sit up, apparently infinitely improved, and again show some interest in his 
toys. These cases are veiy distressing in their effect upon the relatives, 
who had given up the child as hopeless, but now conclude that all danger 
has passed. Unfortunately, if the eyes be examined, it will be found that 
the pupils continue sluggish, dilated, and unequal in size ; the squint, if it 
had been present, still persists, and little hope can be entertained that the 
improvement will be lasting. After a short interval, to the infinite grief 
of the friends, the coma returns as profoundly as before, and then con- 
tinues until the close. 

Increase in the coma is usually associated with effusion into the ven- 
tricles. If ossification of the cranial bones is still incomplete, the fonta- 
nelle, when the effusion occurs, generally becomes elevated and tense. 
Still, it is important to be aware that a large effusion in the ventricles is 
quite compatible with a level or even a depressed fontanelle. 

Convulsive movements generally come on early in this stage. They 
are often partial, and may be confined to twitchings on one side of the 
face or in one arm. Often, however, they are general and more severe. 
Between the seizures the joints are often stiff, and paralysis is more or less 
distinctly marked. Squinting of one or both eyes is seldom absent, and 
there is frequently ptosis, but general paralysis of the face is rarely seen. 

Loss of power in the limbs usually assumes the form of hemiplegia. 
The arm is sometimes affected alone, but the paralysis is said never to be 
confined to one leg. At the end of this stage, when the coma is com- 
plete, the head often becomes retracted upon the shoulders, and the tonic 
rigidity may affect the whole spine ; the joints are stiff ; there is more or 
less complete paralysis of one side ; the pupils are dilated and unequal ; 
there is squint of one or both eyes ; the eyeballs often oscillate ; and tre- 
mors and twitchings may be noticed in the muscles of the face and limbs. 



TUBERCULAR MEITI^GITIS— SECONDARY. 361 

Before death the pulse usually becomes very rapid ; the constipation 
is replaced by diarrhoea ; aphthse appear upon the mouth ; the retracted 
abdomen swells out again with gaseous distention ; ophthalmia may occur, 
and the cornea often ulcerates ; there is generally profuse sweating, and 
acute oedema occurs in the lungs. On the last day the temperature may 
fall to a subnormal level or may rise very high, and sometimes it reaches 
a surprising elevation. Thus, in a little girl, five years of age, the tem- 
perature on the morning before her death was 97.6° ; but froin that point 
it rose progressively through the day and night, until at 7A5 a.m. on the 
following morning, the time at which she died, it was 110°, and two hours 
after her death had only sunk to 107°. 

The average duration of the illness, counting from the first day of 
vomiting, is twelve days. It may, however, run a shorter course, and 
sometimes comes to an end on the sixth or seventh day. In other cases it 
lasts over a longer period, but is seldom prolonged beyond the end of the 
third week. 

The sequence of the phenomena, as given in the preceding description, 
is that ordinarily met with in cases of the primary form of the disease, 
but there are occasional variations in the symptoms which it is impor- 
tant to be aware of. Thus, in exceptional cases the illness begins with 
diarrhoea, and I have known the looseness to persist, with occasional inter- 
missions, throughout the course of the attack, although no ulceration was 
present in the bowels. Vomiting, also, may be a far from prominent 
symptom. Sometimes it is quite absent ; at other times the child vomits 
once or twice, and not afterwards. Again, the pulse may be slow from 
the beginning, or, on the contrary, may be rapid at the onset and never 
afterwards fall in frequency. Still, as a general rule, repeated observa- 
tions will usually detect a slow r pulse at some period of the illness, even if 
it only last a few hours. It is always important in ascertaining the state 
of the pulse to do so at a time when the child is perfectly motionless. The 
headache, too, varies greatly in severity. It may be excessively severe or 
comparatively slight. The intolerance of light is also a variable symptom. 
Sometimes it is extreme. In other cases the child can bear the light with- 
out apparent discomfort. Lastly, the temperature is not always high. It 
may be little raised above the normal level, and in most cases the pyrexia 
lessens at the beginning of the second stage. Indeed, at this period the 
reduction in the fever, together with the diminished fretfulness of the pa- 
tient as he becomes more stupid and drowsy, may excite in the minds of 
the friends false hopes of improvement. It is generally the case that the 
fever is higher in the third stage than at an earlier period. If it rise to a 
high level in this stage it is a sign of approaching death. 

In secondary tubercular meningitis the earlier symptoms of the special 
lesion are masked by the more general phenomena indicative of the suffer- 
ing of the whole system from the tubercular cachexia. This form of the 
disease is the shape the affection invariably takes in infants, and it is not 
uncommon in older children. In these cases nutrition is always greatly 
interfered with. The child is thin, weakly, and miserable-looking. He is 
more or less feverish, although, unless catarrhal pneumonia be present, the 
temperature rarely exceeds 101° ; has no appetite ; often vomits ; and 
appears to be gradually wasting away. Suddenly he is seized with a fit 
of convulsions. This is followed by partial paralysis which involves some 
of the cerebral nerves, notably the occulo-motor ; dilated, sluggish, and 
often unequal pupils ; rigidity of joints, and stupor. In this state he lin- 
gers a few days ; the convulsions are repeated ; the pulse is sinall and rapid; 



362 DISEASE IN C1IILDEEN. 

the breathing is irregular ; the abdomen is retracted, and the child dies 
without any return of consciousness. After death the gray granulation is 
discovered widely distributed throughout the internal organs, and the 
lungs as well as the cerebral meninges are usually the seat of inflammation. 

The convulsions are often very partial in these cases, and may consist 
merely of tonic spasms affecting one or more limbs, with squint or conju- 
gated deviation of the eyes. Sometimes, also, there are slight clonic spasms 
or faint tremors, unilateral or limited to one limb. The outbreak of the 
head symptoms is often preceded by sighing or irregular breathing, flat- 
tened abdominal parietes, and slight twitches in the limbs ; but the slow 
intermittent pulse, which is such a valuable sign in the diagnosis of the pri- 
mary form, is usually absent. Often, before the actual onset nothing at all 
is noticed to give rise to suspicions of intracranial mischief, although our 
knowledge that in every case of acute general tuberculosis affecting a very 
young child such symptoms are likely to occur should lead us to watch for 
them very narrowly. 

In infants the affection, when secondary, almost invariably assumes this 
form, and death usually follows within a few days of the occurrence of the 
head symptoms. In older children the course of the secondary form is 
somewhat longer, and, indeed, the symptoms in some cases may approach 
nearly to the type observed when the disease is primary. Still, there are 
in most cases many differences. Delirium alternating with stupor, without 
convulsions, squinting, or other form of paralysis, may be the only sign 
that the meninges are affected. Sometimes there is repeated vomiting, 
with some wandering of mind and intellectual sluggishness, so that the 
child seems not to understand questions addressed to him, and when told 
to put out his tongue makes no effort to obey. The disease may even 
reach its termination without any more positive signs of intracranial lesion 
being noticed. Indeed, in these cases the variations in the symptoms are 
infinite ; but if the existence of general tuberculosis has been ascertained, 
we shall be at no loss to explain the meaning of any new symptoms which 
may arise from the head at this late period of the illness. 

Many anomalous cases of secondary tubercular meningitis occur in 
children suffering from cerebral tubercle. This is a chronic disease which 
continues often for months, and is accompanied by more or less severe 
symptoms pointing to the brain. Fever is usually present, and sickness 
and headache, which are characteristic symptoms at the onset of the menin- 
gitis, are also common in the brain tumour. Consequently the recurrence 
of these familiar phenomena is often attributed to the growth, and is sel- 
dom interpreted as indicating a new phase of the illness. In such cases 
the early period of the meningitis passes unnoticed, and the complication 
is seldom recognised before the more violent symptoms which are charac- 
teristic of its third stage are actually present. 

Diagnosis. — It is not always easy at the beginning of an attack of tuber- 
cular meningitis to speak positively as to the nature of the illness. The 
first symptoms are often mild and apparently trifling, and if, misappre- 
hending their importance, we make light of what eventually proves to be 
a fatal disease, the mistake is one which will be certainly remembered to our 
disadvantage. 1 Vomiting and constipation, especially if conjoined with 

1 It is well in all cases, even of apparently trifling febrile derangement occurring in 
children of known tubercular tendencies, to warn the parents that although the case 
appears to be at present one of trifling importance, even such casual disturbances are 
found occasionally to arouse the dormant tendency to mischief and to be lollowed by 
very serious consequences. 



TUBERCULAR MENINGITIS — DIAGNOSIS. 363 

headache, form a very suspicious combination, and if these occur in a deli- 
cate child or succeed to a period, however short, of general failure of 
health, we should view them with serious apprehension. If our suspicions 
are well founded, symptoms soon appear to give them confirmation. The 
pulse becomes slow and intermittent, the breathing is irregular, the child 
gets stupid and drowsy, the pupils dilate and are sluggish, and there may 
be a slight squint. When this stage of the disease is reached, there is 
little room for hesitation. It is principally in cases where the illness varies 
from the normal type that the beginning of the disease gives rise to uncer- 
tainty. Vomiting may be absent. Instead of constipation there may be 
looseness of the bowels. But still, if the child is feverish, complains of 
headache, and has a pinched, distressed expression — if with even trifling 
symptoms he looks really ill, we should never speak slightingly of his 
condition. 

Tubercular meningitis almost invariably begins insidiously, and the 
symptoms have a regular progression. It is seldom ushered in by a con- 
vulsive fit, and if such a seizure occur at the beginning, it is rarely 
repeated. Slighter signs of nervous disturbance may, however, be gener- 
ally discovered by careful observation and inquiry. The child will be 
found to have lately changed in character. From an even-tempered placa- 
ble boy, he has become suddenly irritable and spiteful ; if naturally head- 
strong and independent, he turns strangely timid and affectionate, and is 
moved to tears by a kind word. Often he grows curiously silent and un- 
willing to play or even to speak. Again, he may be noticed to fro^n often 
and avoid the light. He flushes frequently, sighs deeply, and complains of 
headache and giddiness. All these small details assume great value if 
combined with feverishness, vomiting, and a look of care. Drowsiness is 
an early symptom, and when succeeding to the above is very suspicious. 
At the same time the breathing generally becomes unequal, with long 
pauses and deep sighs, and this, itself an important symptom, becomes of 
double value when associated with others pointing in the same direction. 
If now the pulse falls in frequency and is intermittent, without improve- 
ment in other symptoms, the evidence it supplies may be considered con- 
clusive. 

The early period of tubercular meningitis may be mistaken for any of 
the other lesions or derangements which are accompanied by loss of flesh, 
vomiting, headache, and signs of nervous excitement. 

The condition called spurious hydrocephalus, which sometimes occurs 
in exhausted infants as a result of ansemia of the brain, with sluggish cere- 
bral circulation, and is sometimes a sign of thrombosis of the cranial 
sinuses, is usually readily distinguished by the history of severe vomiting 
or diarrhoea, the evident exhaustion of the child, the depressed fontanelle, 
and the normal or even subnormal temperature. This condition is seldom 
seen after the first year of life, and therefore is more likely to be mistaken 
for a general tuberculosis with secondary meningitis than for the primary 
form of the disease. Sometimes older children after an attack of serious 
acute disease may be left in a state of profound malnutrition, in which all 
food excites vomiting, and the stomach seems incapable of retaining or 
digesting even the simplest articles of diet. The child is restless and fret- 
ful, and complains of headache. His skin ceases entirely to act, is dry and 
rough, and the hardened epithelial scales can be brushed off as a fine dust. 
His lips are dry and cracked, his bowels confined, and his urine scanty and 
high coloured. After a time the child becomes drowsy and sinks into a 
stupor in which he dies. In these cases the brain and the internal organs 



364 DISEASE IN CHILDREN". 

generally are bloodless and wasted. A distinction from meningitis may 
usually be made by the low temperature, which even in the rectum is 
often no higher than 97°; the history of the case, the absence of retrac- 
tion of the belly, and the course of the illness, which has not the regular 
progression peculiar to the tubercular disease. 

An acute catarrhal condition of the stomach in a scrofulous child some- 
times presents symptoms — feverishness, vomiting, headache, and constipa- 
tion — which may be mistaken for the onset of tubercular meningitis, more 
especially as, when convalescence begins, the pulse often gets slow and 
intermittent. But in all derangements, as distinguished from grave dis- 
eases, there is an important distinguishing mark, viz., that the patient does 
not look seriously ill. If he be not profoundly depressed by the severity 
of the symptoms, or harassed with pain, his face is placid and shows no 
signs of distress. Moreover, his breathing is regular, and his abdomen 
normal in appearance and not retracted. If, later, the pulse becomes slow 
and intermittent, the slackening coincides with an improvement in the 
symptoms and not with an unfavourable change in the condition of the 
patient. 

Still, even a child suffering from tubercular meningitis has not always 
a haggard, careworn look. Some time ago I saw, with Dr. Miller, of Black- 
heath, a little boy, four years old, who had been noticed to be getting thin 
and pale for six weeks. He was often found asleep on the floor in the 
middle of his play. He flushed up at times and was very fretful, crying 
without cause. 

On November 18th he began to vomit, and the sickness continued 
all through the week. It occurred usually about an hour after food, and 
seemed generally to be induced by movement. The bowels were confined, 
but acted readily after aperients. The temperature at night was about 
100°. 

When I saw the child, on November 25th, he was lying in bed, with a 
slight flush on his cheeks. His pulse was at first 100, and regular ; after- 
wards 80, and slightly intermittent ; respirations, 26, and somewhat irregu- 
lar, for the child occasionally heaved a deep sigh, although his breathing 
was never quite arrested. Temperature (at S p.m.) 98.4° ; eyes bright ; no 
squint ; pupils normal, and acted perfectly ; no photophobia ; no cerebral 
flush ; consciousness perfect, and the boy answered questions readily. He 
said that his head sometimes ached at the back. Tongue furred, white ; 
motions, after aperients, of normal appearance and contained no mucus or 
worms. The belly was deeply hollowed, and the parietes were soft, 
doughy, and compressible ; the liver and spleen were of normal size, and 
the physical signs of his heart and lungs were healthy. There was no al- 
bumen in his urine. 

In this case which was seen on the seventh day of the disease, the gen- 
eral mildness of the symptoms, especially the slightness of the headache 
and the complete clearness of mind of the child at so long a period after 
the beginning of his illness, seemed to tell against tubercular meningitis ; 
but the history of the case, the pulse, the sighing breathing, the deeply 
excavated abdomen, the absence of sufficient signs of digestive derange- ' 
ment to account for his state, and the want of elevation in the temperature, 
which excluded a continued fever — all these symptoms taken together 
pointed very strongly in favour of the tubercular disease ; indeed in a few 
days the child became comatose, and he died shortly afterwards. 

"Cerebral pneumonia" may be accompanied by symptoms which re- 
semble tubercular meningitis ; and as the physical signs of the chest may 



TUBERCULAR MENINGITIS—DIAGNOSIS — TREATMENT. 365 

4 
be normal on the first examination, it is often difficult at once to distin- 
guish the real nature of the disease. There is often delirium and stupor ; 
vertigo may be a prominent symptom ; and the pulse, although rapid, is in- 
termittent. In such a case the history, the absence of prodromata, the per- 
verted pulse-respiration ratio, the greater elevation of temperature, and the 
early occurrence of the head symptoms are not in favour of tubercular 
meningitis; but until signs of consolidation are discovered we cannot ven- 
ture positively to exclude meningeal tubercle. 

In special cerebral disease the course is usually very different from 
that of tubercular meningitis, as the illness almost invariably begins with 
violent nervous symptoms. The phrenitic form of simple meningitis of the 
convexity approaches most nearly to tubercular basic meningitis in its at- 
tendant pheromena ; but here the early symptoms are far more severe 
than in an ordinary case of the tubercular variety. The disease breaks out 
suddenly with violent headache, almost immediately followed by loud, 
often furious delirium ; the temperature is very high from the first ; stupor 
quickly supervenes, and the whole course of the disease is rapid. 

In the secondary form of the tubercular disease the earliest sign of the 
occurrence of the cerebral complication is usually vomiting, and this symp- 
tom should never be disregarded. Often, however, the intra-cranial in- 
flammation may first reveal itself by a fit of convulsions or a squint. In a 
child who, after a period of wasting and general illness, has an attack of 
catarrhal pneumonia in which he is suddenly taken with a convulsive seiz- 
ure, the presence of a secondary tubercular meningitis may be more than 
suspected. 

A basic meningitis is sometimes seen in infants as a consequence of in- 
herited syphilis. The symptoms are identical with those of the tubercular 
form ; but the nature of the illness may be sometimes inferred from the 
appearance of the child and the presence of other signs of the congenital 
malady. 

Cases are sometimes seen in which a child dies with all the signs of a 
tubercular meningitis, although after death no appearance of intracranial 
inflammation or exudation can be discovered, nor can the closest examination 
detect any gray granulations either in the skull cavity or at any other part 
of the body. Such cases occur now and then in most children's hospitals. I 
have seen one or two ; and as far as I know the form of tubercular men- 
ingitis thus simulated is always the secondary form ; i.e., the cerebral 
symptoms do not arise suddenly in an apparently healthy child, but come 
on towards the close of a more or less prolonged febrile attack. 

Prognosis. — Tubercular inflammation of the cerebral meninges is so 
mortal a disease that when the nature of the case is established beyond a 
doubt, a fatal termination is inevitable. The disease is said to have been 
sometimes arrested before the second stage had been reached. In such a 
case it is reasonable to doubt the accuracy of the diagnosis. Probably 
many of the cases in which recovery from a basic meningitis has been 
recorded have been instances of the syphilitic form of the intracranial 
inflammation, which is much more amenable to treatment. 

Treatment. — The disease is so fatal when once established that special 
precautions should be taken in every case where we have ascertained the 
existence of the tubercular diathesis to prevent the development of the 
cachexia, and ward off all influences tending to promote irritation and con- 
gestion of the brain. For the general means to be adopted to strengthen 
the constitution and weaken the diathetic tendency the reader is referred 
to the chapter on tuberculosis. With regard to special measures, we 



366 DISEASE IK CHILDREN. 

should be careful to forbid the more exciting amusements and too boister- 
ous games. The mind of the child should not be overtaxed with protracted 
study, and care should be taken that his intervals of relaxation are frequent 
and regular. 

When the disease is actually established, we can have little hope that 
any treatment we can adopt will succeed in checking the course of the 
illness. The violent measures which it was at one time thought necessary^ 
to employ in cases of tubercular meningitis have been found to be not 
only useless but actually hurtful. Few judicious practitioners would now 
think of applying leeches, of blistering the skin, of running a seton into 
the neck, or of rubbing tartar emetic ointment into the shaven scalp. If 
the case be seen early, perfect quiet in a room carefully shaded from the 
light should be enforced ; ice-bags should be applied to the head, and the 
feet should be kept warm. The bowels must be relieved by a dose of calo- 
mel and jalapine, or compound scammony powder, and in the hope that the 
disease may have a syphilitic origin, the perchloride of mercury, in doses 
of fifteen to thirty drops, can be given two or three times a day. The child 
should be supplied with liquid food in sufficient quantities ; and if he re- 
fuse to swallow, he must be fed through an elastic catheter passed down 
the gullet. Stimulants must be given as seems necessary. 



CHAPTER XY. 

PARALYSIS OF THE PORTTO DURA. 

Facial paralysis from affection of the portio dura of the seventh nerve 
may be a mild or severe complaint according to the cause on which the 
paralysis depends. It is common enough in children, and in them is fre- 
quently a sign of severe and perhaps incurable disease. 

It will be remembered that the facial nerve rises in the floor of the 
fourth ventricle from a nucleus common to jit and the sixth nerve. Thence 
it passes outwards with the auditory nerve, enters the internal auditory 
meatus, and is conveyed by the Fallopian aqueduct to its foramen of exit 
from the skull. It is important to- bear in mind the principal branches 
given off by the nerve in the Fallopian canal, as the seat of the lesion is 
determined by the extent and distribution of the paralysis. Shortly after 
entering the aqueduct, the facial nerve is joined by the large superficial 
petrosal branch of the Vidian nerve. It is by this channel that it conveys 
nervous influence to the velum ; for the Vidian nerve is united with Meck- 
el's ganglion, from which branches descend to supply the muscles of the 
uvula and soft palate. Soon afterwards it is joined by the small super- 
ficial petrosal branch from the tympanic nerve ; and a little farther on it 
gives off the chorda tympani, which joins the gustatory branch of the fifth 
nerve, and is distributed to the tongue. ' 

Causation. — The function of the facial nerve may be interfered with by 
a lesion at any part of its course, from its origin in the floor of the fourth 
ventricle to its periphery. The cause of the paralysis may therefore lie in- 
side the skull cavity, in the Fallopian aqueduct, or outside the temporal 
bone. 

Inside the skull the nerve may be injured by extravasation of blood or 
be compressed by tumours, inflammatory thickenings of the dura mater, 
and by exudations. In the Fallopian canal the nerve may be damaged by 
fracture at the base of the skull, or be destroyed by caries of the petrous 
bone. After leaving the temporal bone the nerve may be injured by the 
forceps during delivery ; or by blows upon the face ; or by inflammation 
set up in its sheath by extension from neighbouring parts, as in parotid- 
itis ; or by an impression of cold, causing rheumatic inflammation of the 
sheath of the nerve. 

The two chief causes which give rise to this condition in children are, 
no doubt, carious disease of the petrous bone, and exposure of the face to 
a current of cold air. Of these the first is a very serious disease, the sec- 
ond a comparatively trifling one. 

1 According to some anatomists the chorda tympani is derived from the nerve of 
Weisberg, and not from the facial. It is intimately connected with the lingual branch 
of the fifth ; and the sense of taste in the anterior two-thirds of the tongue is depend- 
ent entirely upon the chorda tympani, the lingual presiding over general sensibility 
only. 



368 DISEASE IK CHILDREN. 

Caries of the petrous part of the temporal bone is a common conse- 
quence of neglected otitis in the child. According to Von Troltsch, it is 
far from uncommon to find the mastoid cells, with the tympanic cavity, 
and the Eustachian tube the seat of suppurative catarrh in a child who 
had lived and died without the disease having been suspected. This con- 
clition may exist without external discharge, without pain, or any symptom 
by which its presence may be revealed (see Otitis). 

In children under three years of age facial paralysis is not rare. At 
this time of life it is due almost invariably to otitis and caries of bone, with 
suppuration in the sheath of the nerve. Older children may suffer from 
paralysis arising from the same cause, but in them there is increasing prob- 
ability that the loss of power is the consequence of a chill. 

Symptoms. — The first symptom usually noticed by the mother is that 
the child's mouth is drawn to one side when he laughs, or cries. On care- 
ful inspection it will be found that the absence of movement involves the 
whole side of the face. While the features are at rest, the eye on the af- 
fected side is incompletely closed ; the nostril is flattened ; the cheek may 
hang a little, although this is not easy to detect in babies ; and the angle 
of the mouth is slightly lowered. It is when the child cries that the great 
difference between the two sides is seen. Then, on the healthy side the 
eyebrow contracts ; the forehead wrinkles ; the eye closes ; the ala of the 
nose and the mouth are drawn upwards ; and the middle line of the lips is 
pulled far out of the centre of the face. On the affected side, on the con- 
trary, the muscles are motionless ; the eye is open ; and the skin remains 
smooth. If the nerve is affected in the Fallopian canal, the paralysis af- 
fects the soft palate. On looking into the throat, it will be seen that on 
the side of the lesion the arch of the palate is flattened, and that the uvula 
is curved to the sound side ; for the motor fibres which pass through the 
large superficial petrosal nerve and the Vidian nerve to Meckel's ganglion, 
from which the palatine branches proceed, contract the azygos uvulae only 
on the sound side. For the same reason children may complain that their 
mouth is dry and their taste impaired — the chorda tympani, which erects 
the papillae of the tongue and promotes secretion of saliva, no longer con- 
veying the nervous influence. Sensibility is not affected, but babies often 
seem to have a difficulty in swallowing their food ; and if there should be 
loss of power on one side of the soft palate, some of the milk may be oc- 
casionally returned through the nose. An older child complains of great 
inconvenience from food collecting between the gums and the cheek, 
through the action of the buccinator being paralysed. He can no longer 
whistle, and even his speech may be impaired. The half-open eye is apt 
to become inflamed from exposure ; and there may be a flow of tears over 
the cheek as a consequence, according to Duchenne, of paralysis of the 
tensor tarsi muscle, which no longer retains the puncta in its normal posi- 
tion. 

The symptoms which are produced by a lesion affecting the facial nerve 
in the Fallopian aqueduct are well seen in the following case : 

A little girl, aged sixteen months, was admitted into the East London 
Children's Hospital on March 24th. The mother stated that the child 
had been always healthy until two weeks previously, when she had begun 
to be feverish and to be irritable and thirsty. For the same time she had been 
losing flesh and had had some cough. The day before, while sitting up in 
her mother's arms, the child had suddenly fallen backwards in a fainting 
condition, and had seemed to lose consciousness. It was then noticed that 
her face was drawn to the right. On admission there was found complete 



FACIAL PARALYSIS — SYMPTOMS. 369 

paralysis of the left side of the face, and the left eye closed incompletely. 
The uvula was small and showed no distortion. A discharge escaped from 
the left ear, but the mother could not say how long this had been going 
on. On examination of the chest there was impaired resonance at each 
apex, and the breathing was high-pitched and bronchial, with a large 
bubbling rhonchus. Over both sides of the chest dry and moist rales were 
heard. During the first fortnight of the child's residence in the hospital her 
temperature varied between 99° and 100°. She took her food fairly well, but 
seemed to swallow with difficulty, and occasionally fluids returned through 
the nose. The paralysis of the face continued, and the left eye became 
red and congested. The otorrhcea improved ; but the child's temperature 
became higher, and rose to 104.5° in the evening. Then the left cornea 
sloughed, and the patient died suddenly on April 19th. 

After death both lungs were found studded over with small cheesy 
masses. On examination of the left ear the tympanic membrane was de- 
stroyed ; the ossicles were carious and broken down ; the tympanum and 
mastoid cells were filled with pus ; the wall of the tympanum was carious, 
and a probe could be passed though it in the direction of the Fallopian 
canal. There was no inflammation of the brain or its membranes. The 
cranial sinuses were not examined. 

The occurrence of the paralysis is not always attended with symptoms 
of shock, as in the above instance. Usually it is only discovered acci- 
dentally by noticing a deviation in the child's face when it cries. The 
sloughing of the cornea in the case narrated was due to implication of the 
sensory branch of the fifth nerve. 

In the parts supplied by the paralysed facial nerve the loss of power 
is usually complete ; and if the lesion affect the nerve after its passage 
through the internal auditory meatus — that is to say, if the facial nerve 
and no other be implicated, the motion of the tongue is unimpaired, the 
muscles of mastication act well, and there is no loss of power in the levator 
palpebrse or the muscles of the eyeball. In all but the mildest forms the 
paralysed muscles soon lose their irritability, and cease to respond to the 
electric current. 

When the paralysis is due to caries of the petrous bone there is usually 
discharge from the meatus of a very offensive kind, and more or less im- 
pairment of hearing. When the cause of the loss of power is inside the 
skull cavity, we get signs indicating the involvement of other nerves. 
There is squinting, or deafness, or anaesthesia, and hemiplegia may be pres- 
ent. Occasionally it happens that paralysis of the sensory branch of the 
fifth nerve accompanies the facial paralysis. If this nerve be affected at a 
point anterior to the Gasserian ganglion, where it lies on the petrous part 
of the temporal bone, there result loss of sensibility of that side of the 
face, of the conjunctiva, and of the anterior portion of the tongue, also, 
inflammation of the conjunctiva, and ulceration of the cornea. If the nerve 
be affected at a point posterior to the Gasserian ganglion, inflammation 
and ulceration of the cornea do not follow, although the sensibility of the 
face is still affected. If the portia dura be diseased at its origin in the 
nucleus common to it and the sixth nerve, internal strabismus from paralysis 
of the external rectus muscle of the eyeball will accompany the facial pals}'. 

Diagnosis and Prognosis. — If the paralysis is noticed directly after birth 
in a child w T ho has been delivered with instruments, the cause of the in- 
firmity is evident and the prognosis most favourable. In older babies and 
young children it is very important to discover the seat of the lesion. If 
it is due to caries of bone, and the nerve is consequently affected in the Fal- 
24 



370 DISEASE IN CHILDEEN. 

lopian canal, there is an offensive discharge from the auditory meatus, and 
the sense of hearing is more or less blunted. Perhaps, also, we can detect 
a certain degree of flattening of the palatal arch on the affected side, with a 
little twisting of the uvula, but this sign in children whose uvula is small 
is often absent. The existence of impairment or perversion of the sense 
of taste is also impossible to ascertain in young children. In them old 
standing otorrhoea, or even a recent offensive discharge from the meatus, 
combined with facial paralysis, affords suspicion of the strongest kind that 
the facial nerve is affected in the Fallopian aqueduct. The prognosis in 
these cases is very unfavourable. In fact, death usually occurs sooner or 
later from extension of the inflammation to the dura mater and the brain. 
The form of facial palsy which is found in children under the age of three 
years is commonly due to this cause. In an older child, if the paralysis 
has not been preceded by any impairment of the sense of hearing, or by 
otorrhcea ; if his sense of taste is natural, his mouth perfectly moist, and 
his uvula straight, we may conclude that the nerve is affected in the third 
j3art of its course. If, as usually happens in such cases, there is history 
of exposure to cold or of some slight injury to the face, the prognosis is 
favourable although recovery may take some time. 

Treatment. — Facial palsy from pressure of the forceps during delivery 
soon disappears, and little treatment is required beyond frequent frictions 
to the face. Paralysis from cold should be treated by steady frictions with 
stimulating liniments, and the affected side of the face should be wrapped 
up in cotton wool. Electricity is useful. Dr. Duchenne's plan w 7 as to em- 
ploy first the constant current with frequent intermissions, and as the ir- 
ritability of the muscles returned, to make the intermissions less frequent 
and the sittings shorter. He never used faradism until several weeks had 
elapsed after the beginning of the paralysis, although at the later stage he 
allowed its value. Under the use of these measures the tonicity of the 
muscles returns, and the face regains its symmetry some weeks before 
voluntary power is restored. 

Besides electricity and passive exercise, Dr. W. A. Hammond recom- 
mends the early employment of strychnia in sufficient doses to bring the 
patient under the full influence of the drug. He also insists upon the im- 
portance of supporting the affected side of the face by means of a little 
hook placed in the angle of the mouth and fastened to the ear. But me- 
chanical supports of this kind, which depend for their usefulness upon the 
intelligent co-operation of the patient, are not well suited to young children. 

In cases where the palsy is due to disease of bone, little can be done 
in the way of treatment. Our efforts must be then directed entirely to 
the cure of the otitis. 



CHAPTEE XVI. 

ACUTE INFANTILE SPINAL PARALYSIS. 

Acute infantile spinal paralysis, or acute anterior polio-myelitis, is not, as 
was formerly supposed, a disease peculiar to childhood. It is now known 
to occur also in adults, although in them much more rarely than in younger 
persons. This lesion constitutes the ordinary form of paralytic affection 
to which children are liable. It nearly always begins in babyhood — dur- 
ing the time of the first dentition — but often lasts long after the first teeth 
have been completed, and indeed may render the child a cripple for life. 

The disease is never a fatal one in itself, but if death occur from other 
causes in a child so paralysed, no naked-eye changes in the spinal cord 
can be discovered. Consequently the nature of the lesion was long doubt- 
ful, and has only recently been elucidated. Now, however, owing to the 
researches of MM. Charcot, JofYroy, Roger, Damaschino, and others, the 
loss of power has been shown to be due primarily to an inflammation af- 
fecting the gray matter of the anterior cornua of the spinal cord, causing 
atrophy and disappearance of the large multipolar ganglion cells in that 
situation. The reader may be reminded that these large ganglion cells are 
believed to be centres of reflex action and transmitters of impulses received 
through the spinal tracts. They therefore influence the movements of 
muscle. Besides this, they are probably trophic centres and regulate the 
nutrition of tissues. Consequently the disappearance of these cells is fol- 
lowed by impairment or even abolition of reflex and voluntary action in the 
parts with which they are in communication, and also by impaired nutrition 
in muscles, tendons, bones, and joints. 

Causation. — As the disease is mainly limited to the period of the first 
dentition, cutting of the teeth has been supposed to be a cause of the mye- 
litis ; but if this be the case it is probably so only indirectly. An infant 
feverish from teething is in a high state of nervous irritability. His diges- 
tion is impaired, and his pyrexia renders him exceptionally sensitive to 
chill and other causes of inflammatory and catarrhal disorder. For this 
reason pulmonary and intestinal derangements are common at this period 
of life. But these ailments cannot be said strictly to be caused by denti- 
tion, except in the sense that the process of teething, by making the child 
feverish, heightens his susceptibility to ordinary injurious influences. So, 
also, in the case of this disease, an infant, when feverish, is more likely to 
be affected by causes which produce the myelitis than he would be at an- 
other time when bis temperature is normal, his digestion good, and his 
nervous system undisturbed. "What these causes may be is doubtful. The 
inflammation is often attributed to chills, and there is no doubt that the 
season of the year has a distinct influence in inducing the attacks. Drs. 
Wharton Sinkler, of Philadelphia, and Barlow, of Manchester, have made in- 
quiries into this matter. Out of one hundred and forty-nine cases collected 
by the former physician no less then seventy-seven occurred in the months 
of July and August. In Dr. Barlow's one hundred and eleven cases forty- 
eight occurred during the same months. Now July and August, although 



372 DISEASE IN CHILDREN. 

the hottest months in the year, are also those in which alternations of tem- 
perature are most rapid and unexpected, and in which, therefore, sudden 
chills are very likely to be incurred. If the child at the time of the change 
is depressed and exhausted by previous intense heat — as he is apt to be in 
a tropical climate — the sudden lowering of the temperature is the more 
likely to produce an injurious effect. The disease sometimes occurs after 
typhoid fever : Dr. Buzzard has known it to come on after measles ; and 
the paralytic attack appeared in a patient of my own — a little girl of two and 
a half years old — during convalescence from an obstinate chronic diarrhoea. 
Both sexes appear to be subject to it in an equal degree ; and, apparently, 
robust health is no protection from its attacks, for it as often affects a con- 
stitutionally healthy child as a cachectic and weakly one. 

Morbid Anatomy. — The lesion is limited to the spinal cord, the brain 
being unaffected. An inflammatory process attacks the anterior cornua 
and produces certain changes in the gray matter itself, in the roots of the 
nerves which take their origin in this situation, and in the muscles, tendons, 
bones, and joints to which they are distributed. 

In the gray matter the changes are not appreciable by the naked eye, 
except that in old standing cases a certain diminution in bulk, with increased 
consistence of the affected parts, can be sometimes detected. By careful 
microscopic examination, however, the changes can be distinctly recognised. 

The inflammatory process is diffused through the gray matter forming 
the anterior horns ; but is more intense at certain points, notably the 
cervical and lumbar enlargements. As a consequence, areas of softening 
can be seen, more or less sharply defined, seated towards the front of one 
or both cornua. In these areas the tissue is soft and friable, the blood- 
vessels are fuller than natural, and numerous granulation cells are seen 
with an increase in the amount of connective tissue. The most striking 
change consists, however, in the fact that the large ganglion cells have almost 
completely disappeared, and the few which are left are greatly atrophied 
and degenerated. The nerve fibres and axis cylinders are also destroyed, 
and the anterior roots are degenerated and wasted. As a consequence of 
these changes the anterior horns look small and shrunken at the spots where 
these diseased foci are situated. Although the diseased process is thus 
concentrated in certain patches, the gray substance generally is not com- 
pletely healthy. Throughout the whole dorsal portion of the cord the 
gray matter is often more or less affected. Granulation cells may be seen 
to be scattered through the tissue ; the nuclei are multiplied ; the blood- 
vessels are dilated and ganglion cells here and there have disappeared. 

The above changes constitute the first stage — that of active inflamma- 
tion. As the acute process subsides improvement takes place in parts 
where the gray matter has not undergone entire destruction. But in 
other regions, where the disintegrating process has been complete, further 
changes ensue. These consist in a more extreme wasting and shrinking of 
the anterior horns, so that the diminution in bulk becomes visible to the 
naked eye. The disease is most marked in the cervical and lumbar 
enlargements. In the affected areas there is complete destruction of all 
nerve fibres and ganglion cells. Even if a few are left, they are degener- 
ated and shrivelled. The area becomes filled with a fine fibroid connec- 
tive tissue, rich in nuclei, and the blood-vessels are hypertrophied. Even 
the anterior white columns become more or less degenerated. Their 
neuroglia is thickened, their nerve fibres are atrophied, and the develop- 
ment of the columns is retarded, so that they look small and narrow. 
This is, however, probably a secondary affection, and is not necessary for 






INFANTILE PAEALYSIS — MOKBLD ANATOMY — SYMPTOMS. 373 

the complete development of the symptoms. Stated briefly, the lesion 
which constitutes infantile paralysis may be said to be an acute myelitis 
of the anterior gray cornua, leading to circumscribed patches of sclerosis 
with complete destruction of the large ganglion cells and other nerve 
elements. 

The changes which have been described supply an explanation of the 
peculiar phenomena observed in the disease. The striking limitation of 
the paralysis to certain muscles, or groups of muscles, and the complete 
immunity of others, is due to the concentration of the lesion into certain 
circumscribed areas ; while the early resolution of the inflammation in the 
larger portion of the tissue attacked accounts for the disappearance of the 
first severe symptoms, and the restitution of power in many of the muscles 
primarily affected. 

The paralysed muscles also undergo atrophy and degeneration. They 
become at first paler and softer, then grayish or reddish yellow, with bands 
of connective tissue, and yellow lines or streaks of fatty tissue. The micro- 
scope shows at different stages the fibres wasted, and their striation indis- 
tinct, with hyperplasia of the cells of the sarcolfemma ; then the fibres 
cloudy with numerous fat molecules ; finally, almost complete absence of 
muscular fibre. The normal structure is often replaced by an increased 
formation of connective tissue, so that what was once a muscle becomes a 
mere fibrous bundle ; in other cases we find substitution of the normal 
muscular substance by adipose tissue, and by this means the original 
volume of the muscle may be actually increased. 

Fatty degeneration is not an invariable consequence of the muscular 
paralysis. Even when it occurs, it is often not universal, and proceeds 
much faster in some bundles of fibres than in others. 

The bones as well as the muscles become wasted. Their development 
and growth are retarded, and their density diminished. 

Symptoms. — The attack is sudden, and the paralysis reaches its height 
at once, both in distribution and degree. In many cases the child exhibits 
no symptoms of illness. He goes to bed to all appearance perfectly well. 
In the morning one or more of his limbs is found to hang loosely and to 
be motionless, otherwise he shows no sign of ill health. In quite young 
babies, who cannot walk, the loss of power may remain unnoticed for 
several days. In a second class of cases the symptoms are a little more 
marked. A child who has been put to bed in his usual health is seized in 
the night with fever. He cries and is very restless. In the morning more 
or less extensive paralysis is discovered. In a third class of cases the child 
is feverish and poorly for several days before the paralysis occurs, some- 
times he is delirious, or he may have an attack of convulsions followed by 
stupor. In all cases, probably even in those where the symptoms are the 
least accentuated, there is some preliminary fever, but this may last only a 
few hours, and is often unnoticed by the attendants. 

The paralysis is complete. It may be widely distributed, or may be 
limited to one muscle or a group of muscles. It may affect all four limbs; 
it may attack only the lower extremities ; it may assume the hemiplegic 
form and fix upon the arm and leg of one side ; or, again, it may settle upon 
one limb only — in such a case the right foot is said to be the part most 
frequently selected. In this form of paralysis the face l and parts sup- 

1 With regard to the absence of paralysis of the face it is right to say that Dr. Buz- 
zard has recorded a case which appears to be one of undoubted infantile paralysis in 
which facial paralysis was noted. Dr. Buzzard attributes this exceptional phenomenon 
to an extension upwards of the inflammatory process into the medulla oblongata. He 



374 DISEASE IN CHILDEEN. 

plied by cerebral nerves are never affected, the intelligence, after the first 
onset, is never impaired, and control over the rectum and bladder, at any 
rate after the first few days, is never lost. Sensibility in the paralysed 
parts remains in every way normal ; there is no pain anywhere ; no rash 
upon the skin ; no tendency to the formation of sores or sloughs upon 
parts exposed to pressure ; no rigidity of the joints. The affected limb is 
perfectly flaccid and painless, but also perfectly motionless. In some rare 
cases the onset of the disease has been said to be attended by pains in the 
back and limbs, and by hyperesthesia of the skin ; but these phenomena 
are not directly the consequence of the spinal lesion, and form no neces- 
sary part of the group of symptoms which are held to be characteristic of 
infantile paralysis. 

The flaccidity of the paralysed muscles is accompanied by a loss of re- 
flex phenomena and a diminution or complete disappearance of the nor- 
mal contractility. This takes place early in certain muscles, so that in 
the course of a few days they may be found to respond faintly or not at 
all to faradic stimulation. "While, however, the muscles have ceased to re- 
act to the strong faradic current, they will still respond to slow interrup- 
tions of the constant current. When contractions are obtained by this 
means in a muscle which has lost all faradic contractility the phenome- 
non is called "reaction of degeneration." It implies that the muscle for 
the time is physiologically cut off from the influence of the spinal cord. 
Besides this, early signs are noticed that the nutrition of the limb is no 
longer efficiently maintained. The part is cold and often looks purple ; 
the pulse is smaller ; the fat becomes absorbed ; the muscles waste ; the 
ligaments of the joints are relaxed and there is even a slackening of growth 
in the bone. These trophic changes are usually marked, and generally 
continue after apparent restoration of power in the affected limb. 

The paralysis is at first complete and much more extensive than it , 
afterwards becomes. After some weeks, or perhaps months, a partial re- 
covery takes place in the muscles whose faradic contractility had not been 
entirely destroyed. Sometimes this restitution of motor power is perfect, 
and, except for the impaired nutrition in the affected limb, the child may 
seem to be well. More usually, however, certain muscles, or groups of 
muscles, still continue disabled ; and when the paralysis has thus limited 
itself, the parts which remain crippled are in most cases permanently use- 
less. 

When the paralysis is at first extensive, there appears to be no definite 
rule as to the parts which are afterwards to recover their power. If an 
arm and a leg are both affected, the one limb does not necessarily recover 
sooner or more completely than the other. The only indication is the 
persistence of contractility in the palsied muscles. Each muscle should 
be carefully tested by the faradic current, and in those whose contractility 
is not destroyed we may hope for eventual recovery. Cases have been re- 
corded — notably by Dr. Kennedy — in which the limbs recovered early and 
completely without the disease leaving any trace of its passage ; but it has 
been doubted if in such instances the lesion is the same as in those where 
recovery is slow and more or less imperfect. 

believes that facial paralysis occurs so seldom because the acute affection invading the 
bulb is hot likely to spare the nuclei of nerves essential to life, for if it attacked the 
nuclei of the vagus sudden death would be the consequence. He suggests that cases 
of sudden or rapid death in young children may be sometimes due to the disease strik- 
ing the medulla oblongata with the same suddenness with which it usually attacks the 
anterior gray matter of the spinal cord. 



INFANTILE PAKALYSIS — SYMPTOMS. 375 

In course of time changes take place in the muscles which remain per- 
manently paralysed after the general restoration of power. This stage of the 
disease is called the period of atrophy ; for the affected muscles waste, and 
at the same time the slackening of growth in the bone becomes a notice- 
able feature in the case. This arrest of development in the affected lirub 
has been already referred to. It is a variable phenomenon and is not al- 
ways present. When it occurs, it does not appear to be proportioned to 
the severity of the disease as to muscular wasting and paralysis ; but may 
be present in a mild case, and absent, or nearly so, in a severe one. Ac- 
cording to Volkmann, it has been seen in cases of the most transient infan- 
tile paralysis where the muscles quickly recovered their power, and atrophy 
of special muscles was not noticed. As the growth and development of 
the unaffected limbs proceed in the normal manner, the difference between 
the two sides is often very evident. 

The wasting of the muscles permanently paralysed sometimes begins 
early, and, according to Duchenne, may be evident at the end of a month. 
As a rule the permanent paralysis is not widely diffused. It is not com- 
mon to find a whole limb shrunken and useless, although even this mis- 
fortune may occur. Usually it is a group of muscles, or even a single 
one, which is thus disabled ; and in practice certain parts more than others 
are found to undergo the atrophic change. In the leg the common exten- 
sor of the toes, the peronei longus and brevis, the tibialis anticus, and 
sometimes the gastrocnemius may become atrophied ; in the thigh, parts 
of the triceps extensor; of the muscles attached to the upper extremity, 
the deltoid, the serratus magnus, and some of the muscles of the forearm. 

One of the most important and characteristic results of the disease con- 
sists in the paralytic contractions which almost invariably occur when mus- 
cles are permanently disabled, and constitute various kinds of deformity. 
They are especially common in the feet, and are the principal cause of the 
different forms of clubfoot which develope in the child after birth. The 
contractions occur not in the paralysed muscles, as a rule, but in those 
which still retain their contractile power. They begin early, and tend to 
increase as time goes on. This contraction of unaffected muscles, or of 
muscles only partially affected, was attributed formerly to the influence of 
the so-called Ck muscular tonus." It was supposed that a constant stimulus 
proceeded from the spinal cord, and kept all healthy muscles in a state of 
persistent slight contraction. In the normal condition, it was said, oppo- 
site muscles neutralise each other ; but if the muscles become paralysed on 
one side, so that the contracting power on that side is abolished, the limb 
is drawn to the affected side by the action of the " tonus" in the unaffected 
muscles. This theory was combated by Werner, who "maintained that the 
contraction could be explained without recourse to the imaginary tonus. 
He asserted that when one set of muscles is paralysed, there is no deform- 
ity until the opposite set of muscles is put into action. The limb is then 
drawn to that side and cannot be replaced by the paralysed antagonistic 
muscles. It therefore remains in its new position until replaced, or until 
it falls back again by its own weight. Consequently, it must happen that 
the limb is often and long in one position, for the muscles once contracted 
remain so because the antagonistic muscles can no longer act. After a 
time they lose the power to relax, and a permanent contraction becomes 
gradually established. 

But even this theory does not account for the whole of the facts, for, 
as was pointed out by C. Hiiter, it is not always the muscles anatomically 
opposed to the paralysed groups which undergo contraction ; and indeed 



376 DISEASE IN CHILDREN. 

the deviation sometimes occurs in the direction of the paralysed side. 
The real cause of the deformities of the foot appears from the researches 
of H liter, Volkmann, and others, to be only partially the unopposed action 
of healthy muscles and inability to antagonise their contractions. Far 
more important agents are the weight of the affected part itself and the 
greater pressure thrown upon it when in use. For instance, the common- 
est deformity of the foot is the talipes equino-varus ; but this is exactly 
the position in which the foot will fall when the ankle-joint is not acted 
upon by its muscles. If a child be made to sit upon the edge of a table, 
with his legs hanging down, the foot instantly falls into the equino-varus 
position. In paralysis of the limb, if the child has not walked, this is the 
form the deformity invariably takes. The foot assumes this position, and 
the shortened muscles in time become permanently contracted. The ar- 
rest of growth in the bone, which is generally present, promotes the for- 
mation of this deformity, for the affected leg being shorter than the other, 
the child has to point the toes in order to reach the floor. If the paralysis 
occur in a child who has already learned to walk, the flat foot (talipes val- 
gus) is the usual form of distortion, and is, according to Volkmann, irre- 
spective of the actual muscles paralysed. When the patient brings his 
weight to bear through the leg upon the sole placed flat on the ground, 
the foot, being no longer braced up by the paralysed muscles, curves out- 
wards until checked by the ligaments. By repetition of this action the 
ligaments stretch, and the bones on the compressed side are interfered 
with in their growth. The talipes valgus thus formed is less perfect than 
the same deformity produced by over-exercise and fatigue in a child with 
unparalysed muscles, for during rest the foot is brought again by gravita- 
tion into the equino-varus position. The shortened muscles are therefore 
again drawn out, and their contraction is less complete, so that the joint is 
comparatively loose. 

When the muscles of the thigh are permanently weakened, there is no 
contraction about the knee unless the child attempt to aid himself by the 
use of crutches. Children in whom there is partial paralysis of the quad- 
riceps femoris walk, says Volkmann, exactly like a person who wears an 
artificial leg. To get such a leg to support the weight of the body with- 
out bending the knee, the weight must be thrown in front of and not be- 
hind the joint. Every time that the body rests upon the weakened limb, the 
weight is thrown forwards, so that the knee is in a state of complete exten- 
sion, and the posterior ligaments are put upon the stretch. These after a time 
relax, and the knee is over-extended so as to produce a genu recurvatum. 

In the arm, the elbow-joint is little affected. It remains quite free, and 
no contractions occur unless the arm is kept permanently in the bent posi- 
tion, as when worn constantly in a sling. When the paralysis is so marked 
that the hand is useless, the power of supination of the arm is soon lost, 
for the child, having no occasion for the movement, soon ceases to employ 
it. The wrist becomes slightly flexed, and the fingers, completely clenched 
upon the palm, undergo contraction in that position. This is the position 
the fingers assume when left to themselves ; and if the flexors are not used, 
or are not passively stretched, they become contracted. The shoulder is 
flattened, and if the muscles proceeding from the thorax to the arm are ex- 
tremely weakened, the capsule is pulled upon by the dead weight of the 
arm and becomes permanently stretched, so that a distinct interval is felt 
between the head of the bone and the socket. Id this case the affected 
arm, by measurement from the acromion, may seem longer than the sound 
one. 



INFANTILE PAEALYSIS — DIAGNOSIS — PROGNOSIS. 377 

From what has gone before it will be noticed that cases of infantile 
spinal paralysis fall naturally into two classes : those in which complete 
recovery takes place in all the muscles affected, after the lapse of weeks or 
months ; and those in which power is completely restored in some muscles, 
while others remain permanently useless, and the disease ends in atrophy 
and deformity. In the muscles in which the paralysis is likely to be last- 
ing, faradic contractility disappears at a very early date — usually before the 
end of the first week, or in the course of the second. According to the 
elder Duchenne, muscles which retain some degree of faradic contractility 
on the seventh or eighth day may be expected to recover their power, and 
this the more rapidly the less their faradic irritability has been weakened. 

Diagnosis. — In a case which is seen at an early period of the disease 
the symptoms are so characteristic that it is difficult to mistake this form 
of illness for any other lesion of the nervous system. But every case of 
paralysis with atrophy is not a case of infantile spinal paralysis. To iden- 
tify the disease with accuracy we must require all the essential phenomena 
of the affection, viz., complete motor paralysis without alteration of sensibil- 
ity or pain in the back or elsewhere ; rapid loss of faradic excitability ; a 
normal temperature ; absence of paralysis of the face or of the sphincters ; 
complete flaccidity of the limb, without stiffness or contraction of the 
joints ; marked coldness of the affected parts, and no tendency to the for- 
mation of sores upon the skin. 

In acute generalised myelitis, where the whole of the gray matter is in- 
volved and a large part of the white columns, there is lessened cutaneous 
sensibility ; there is paralysis of the sphincters, so that the child can no 
longer control the bladder or the bowel ; there is an increase of reflex ex- 
citability ; sores form readily on the parts exposed to pressure ; the urine 
is alkaline, purulent, and offensive, and, as a rule, atrophy in the affected 
muscles does not occur. 

Hemorrhage into the cord produces a sudden paralysis, which is fol- 
lowed by atrophy of the affected muscles and loss of reflex excitability ; 
but here also there is diminution of cutaneous sensibility, the sphinc- 
ters are paralysed, and bed-sores form early. 

Paralysis of cerebral origin may be distinguished by the affection of 
the cerebral nerves, such as squinting, facial paralysis, etc. ; by the 
palsy being accompanied by tension of the muscles and spasmodic contract- 
ures-; by the preservation of electrical irritability ; by the stiffness and 
extension of the joints ; by increased excitability of tendons, and by the 
absence of atrophy. 

In spasmodic spinal paralysis the loss of power is incomplete, and occurs 
slowly and insidiously ; muscular tension and contractions are present ; 
there is increased irritability of the tendons, and the affected muscles do 
not atrophy. 

The course of infantile paralysis is also very characteristic. The rapid 
restoration of power in the larger number of muscles affected and the 
complete paralysis of others is very peculiar ; also the arrest of growth, 
which embraces the whole of the region first affected, is a very striking 
phenomenon. At a later period, when contractions occur in the limb, 
the resulting deformity may be distinguished from congenital distortion 
by the very partial atrophy of muscles, the striking looseness of the liga- 
ments of the joint, and the permanent coldness of the part. 

Prognosis. — As infantile paralysis is not a fatal form of illness, our chief 
anxiety must be to estimate the chances of complete recovery in the par- 
alysed muscles. For our own comfort and that of the friends we may re- 



378 DISEASE IN CHILDREN. 

member that complete recovery, or at any rate vast improvement, is the 
rule and not the exception. Careful testing with the faradic current will 
give us very accurate means of determining in which muscles speedy res- 
toration of power may be anticipated, and in which of them persistent 
paralysis is to be feared. The muscles which have lost all physiological 
connection with the spinal cord no longer respond to the induced current, 
while they react to slow interruptions of the constant current (reaction of 
degeneration). This change takes place very rapidly. Faradic irritability 
is enfeebled as early as the third or fifth day, and is lost by the seventh or 
eighth. 

In testing the irritability of the muscles at this period a weak current 
should be used — one just sufficient to cause contraction in healthy mus- 
cles. Every muscle which does not react to the faradic current after the 
lapse of a fortnight from the beginning of the illness is likely to be per- 
manently disabled. Still, according to G. Sigerson, muscles which have 
long ceased to contract may sometimes regain their faradic contractility 
and recover their power more or less completely. On the other hand, in 
the muscles which retain some amount of faradic irritability, however 
faintly they may react to the current, return of power may be confidently 
predicted. Even when recovery from the paralysis is complete, the child 
is still liable to some arrest of growth in the affected limb ; and it is well 
to warn the friends of the patient of this possible consequence of his ill- 
ness. 

Treatment. — If we have the opportunity of seeing the child immediately 
after the occurrence of the paralysis, we should keep him perfectly quiet 
in bed, clear out his bowels with a brisk aperient, and employ counter- 
irritation to the region of the spine. By the repeated application of mus- 
tard poultices, first to one part, then to another, of the spine, a derivative 
action may be kept up as long as the skin will bear it. During the early 
days of the disease it is well to insist upon a prone position, varied occa- 
sionally by laying the patient on his side. The dorsal position, which 
favours congestion of the vessels within the spinal canal, should, if possi- 
ble, be avoided. The child should be put upon a diet of milk and broth, 
and care should be taken that his bowels act regularly once a day. While 
there is any fever Dr. Althaus recommends a daily subcutaneous injection 
of a solution of Bonjean's ergotine — a quarter of a grain for a child of 
twelve months. At first no local treatment is admissible to the paralysed 
muscles ; and the faradic current should be used only for diagnostic pur- 
poses an>d not as a therapeutic agent. But immediately any recovery of 
power begins to be noticed, we should employ the faradic current daily, so 
as to aid the restoration of the affected muscles. If there is at first no re- 
sponse to the induced current, the continuous current, with slow inter- 
ruptions may be employed. It is advisable to use a current of sufficient 
strength to cause a visible contraction of the muscles. This, however, is 
often impossible with children. Even a weak application may cause such 
agitation and alarm that its employment has to be discontinued. We 
should not in any case use a strong current at first. Probably a weak 
current, in its influence upon the nutrition of the muscle, is jDreferable to 
none at all. Dr. Gowers recommends that in the beginning such a strength 
should be employed as the child will bear without much emotional disturb- 
ance, and if care be taken not to alarm the child at the first, a current of con- 
siderable strength can be perhaps made use of afterwards. 

Besides electricity other means should be used. The paralysed limb 
must be kept warm with cotton wadding. This is a matter the impor- 



INFANTILE PARALYSIS — TREATMENT. 379 

tance of which has been very properly insisted upon by Dr. R. J. Lee. If 
the affected parts are very cold, they may be rubbed several times a day 
before the fire ; and hot applications of any kind — bags of hot salt, brae, 
hot flannel, etc., may be kept in contact with the limb to maintain its tem- 
perature. Great assistance will also be derived from vigorous shampooing. 
It is advisable to order stimulating liniments for this purpose, as frictions 
are always employed with more energy if something is given "to be 
rubbed into the skin." The child should be also encouraged to use the 
weakened limb as much as possible ; arid Volkmann insists strongly upon 
the worse than uselessness in these cases of crutches or other forms of 
mechanical support. 

It is usual to give strychnia to these patients, either internally or by 
subcutaneous injection. The remedy has probably little influence in re- 
storing power to the disabled muscles, but as a general tonic its use may 
be not without value during the stage of recovery. It may be combined 
with iron and quinine. 

In most cases of infantile paralysis, when recovery does not take place 
within the first two months, the course of the disease is long and tedious, 
and improvement goes on but slowly. Still, our efforts are eventually re- 
warded by a striking return of power even in cases which at first had ap- 
peared almost hopeless. 

The cure of the deformities resulting from atrophy and contraction of 
muscle come under the department of the surgeon. 



CHAPTEE XVII. 

SPASMODIC SPINAL PARALYSIS. 

Spasmodic spinal paralysis, sometimes called spastic paraplegia, appears 
from the researches of Charcot and of Erb to be due to a sclerosis of the 
lateral columns of the cord. The disease, which consists in a gradually 
advancing weakness or paralysis of the limbs — generally the legs — is some- 
times seen in children and even in young babies ; indeed in many cases it ap- 
pears to be congenital. Like infantile spinal paralysis the lesion is accom- 
panied by no disturbance of the cerebral functions, no affection of sensation, 
and no loss of control over the bladder and rectum ; but, unlike infantile 
paralysis, the affected muscles seldom waste, there is excessive rigidity of 
the joints, and the tendinous reflexes, instead of being abolished, are in- 
creased in activity. 

Causation. — The lesion may develop itself in the earliest childhood. 
Its causes are unknown. Seligmueller has recorded an instance in which 
four children of the same family suffered from a form of the affection. 

Morbid Anatomy. — No cases of death from this disease have been no- 
ticed in children ; but in adults the sj^mptoms have been connected by 
Charcot with degeneration of the lateral columns of the cord. On section 
of the cord the gray degeneration is seen to be symmetrical and to occupy 
the lateral columns on each side of the cord. The diseased region, as 
seen on the surface of the section, is triangular in shape, and reaches in- 
wards to the anterior gray cornua, outwards to the pia mater ; in front it 
passes gradually into the healthy substance of the columns. The degen- 
eration is not in patches, but appears to be diffused over the greater por- 
tion of the length of the cord, and may reach up to the medulla or even 
beyond it. In some spots the process is more intense than it is in others. 
On microscopical examination of the degenerated portions, the neuroglia 
is found to be thickened, the nerve fibres to be degenerated and wasted, 
and the ganglion cells to be cloudy and swollen, or atrophied, pigmented, 
and finally almost destroyed. 

Symptoms. — Whatever may be the age of the child when he first comes 
under observation, we shall generally find that the symptoms date back to 
the period of infancy, and that they were first noticed only a few weeks or 
months after birth. On questioning the mother we commonly hear that 
when quite a baby the child's legs were stiff, and that on this account 
washing and dressing him was a troublesome matter ; that although able 
to move his legs when lying down, he could never stand, and that any at- 
tempt to do so increased the stiffness. If he did succeed in walking at an 
age long after that at which a healthy child can run alone, he was never 
firm on his legs, and soon became weaker and tumbled about. Then the 
power deserted him altogether, and when placed on his feet his legs be- 
came stiff' and crossed, the toes touching the ground but the heels being 
raised. As there is no fever, pain, or evident impairment of nutrition, and 



SPASMODIC SPINAL PARALYSIS— SYMPTOMS. 381 

as in many cases the mental development is satisfactory, the weakness is 
looked upon as a personal peculiarity which the child will "grow out of," 
and he seldom comes under observation until the disease is fully devel- 
oped. 

In a child so afflicted two phenomena are at once noticed : there is 
weakness of the lower limbs, and the joints are stiff, and become stiffer 
when handled. 

On examination we find that the legs are moved awkwardly and with 
difficulty. As the child lies in his cot the limbs are extended and only 
slightly Hexed, and the patient may have some power of bending his joints, 
although some are moved with greater facility than others. The muscles 
feel rigid to the touch, and when the joints are forcibly flexed — which can 
be done without inflicting pain upon the child — they straighten again ab- 
ruptly, as if moved by a spring. Handling the limbs increases the rigidity 
of the joints, and often the mere approach of the physician appears to have 
the same effect. Movement, whether active or passive, produces no tremors 
in the affected limbs. It only increases the rigidity of the muscles. 

When the child is held under the arms, so as to feel the ground with 
his feet, directly he attempts to walk the thighs are closely pressed together, 
the knees are sightly bent, the feet are inverted, and the ankles extended 
so that only the points of the toes touch the floor ; the legs become rigid 
and soon cross one over the other. In bad cases the heels are not brought 
into contact with the ground at all. Sometimes the child, although he 
cannot walk, is able to stand, supporting himself against some object. The 
rigidities appear to contribute to his helplessness as much as the motor 
weakness ; and sometimes the attempt at voluntary movement, conflicting 
with the stiffness of the muscles, results in a sort of chorea. 

The back is often very weak, and the muscles of the abdomen may be- 
come hard when the skin is irritated. Control over the sphincters is not 
interfered with ; there is no paralysis of the face, nor any tendency to the 
formation of sores or sloughs upon the parts exposed to pressure. The 
degree of intelligence varies in different cases. Often the child seems as 
quick as others of his age, but sometimes he is dull and stupid. Articula- 
tion may be affected, but, as a rule, the patients speak readily and clearly. 

Occasionally the arms are affected. In a case reported by Dr. Gee — 
a little girl, eight years old, in whom the paralysis had existed certainly 
from the age of twelve months, perhaps from an earlier period — the arms 
as well as the legs became stiff when the girl was noticed. The arms were 
rotated outwards ; the elbows were strongly extended and the wrists pro- 
nated ; the hands were also extended strongly and thrown back at the 
wrist ; the fingers were flexed. The child could move the opposing mus- 
cles, but with difficulty, and after movement the arms soon returned into 
the position described. The left arm was more affected than the right. 
Dr. Gee has described eight cases of this interesting malady, of which the 
first was observed before the publications of Erb and Charcot had attracted 
general attention to the disease. 

The constant rigidity of the muscles affected is not accompanied, as a 
rule, by any wasting, although in exceptional cases, when the disease is of 
long standing, one or more (not all) of the implicated muscles may show 
some signs of atrophy. The rigidity is a permanent phenomenon, persist- 
ing during sleep, and only disappearing temporarily when the child is placed 
under the complete influence of chloroform. The tendinous reflexes are 
more active than in the normal state, and the response to faradism is rapid 
and energetic. Sensation is unimpaired. 



382 DISEASE IN CHILDREN. 

In many cases the actual amount of weakening of the muscles appears 
to be slight. The impediment to walking seems to be more the result of 
rigidities and contractions of muscles, which prevent the foot and limb from 
being placed in a fitting position to support the weight of the body and 
frustrate the voluntary impulse, rather than of any actual paralysis. From 
observations made upon the adult sufferer, contractions are found to occur 
as a later phenomenon, the muscles being merely rigid at first without any 
shortening in their length. When the contractions come on the paresis 
becomes more noticeable. Eventually it may amount to complete loss of 
voluntary motor power. This is, however, generally of unequal intensity 
in different regions, being well developed in certain groups of muscles, im- 
perfect in others. Usually the disease is more advanced in one of the 
limbs than it is in its fellow. 

If a child, the subject of this disease, be able to walk, his gait is very 
peculiar. The patient behaves as if giddy, and sways from side to side. 
His limbs are widely separated, and he moves each leg awkwardly forward, 
often sliding it along the ground. The tendency appears to be to point 
the foot so that the heel is not in full contact with the floor. Conse- 
quently the toes are apt to catch at any unevenness of the ground, and the 
child would fall on his face if not supported. 

As the disease advances all the symptoms become intensified. The 
rigidities, the contractions, the paresis, and the reflex irritability, all be- 
come increased. The lesion does not appear to be fatal to life. Of its 
later stages little is known, for after a certain degree of intensity is reached, 
and the patient has been rendered quite helpless, the disease seems to 
undergo no further change. 

Diagnosis. — The essential features of the disease are a slowly growing 
paralysis of the lower extremities, without wasting, but accompanied by 
excessive spasmodic rigidity of muscle and increased activity of the tendi- 
nous reflexes. The disease is therefore readily distinguished from infan- 
tile spinal paralysis, in which wasting and arrest of growth in the affected 
limb are the rule ; the joints, far from being rigid, are excessively relaxed, 
and the tendinous reflexes are abolished. 

General acute myelitis resembles the spastic disease in its increase of 
reflex excitability and absence of atrophy, but differs from it by producing 
paralysis of the sphincters, diminishing the cutaneous sensibility, and pro- 
moting the formation of bed-sores. Besides, there is a well-defined hori- 
zontal limit beyond which the disease does not pass, and there is no ap- 
proach to the muscular rigidity which is such a characteristic feature of 
spasmodic spinal paralysis. 

In paralysis of cerebral origin the loss of power is accompanied by ten- 
sion of muscle and spasmodic contractions, the joints are stiff and ex- 
tended, the muscles do not atrophy and continue to respond to faradism, 
and the reflex irritability of tendons is preserved. But in such a case there 
is paralysis of cerebral nerves, the loss of power is hemiplegic in distri- 
bution, the rigidities and contractions are very late to occur, and sensa- 
tion as well as motion is affected. 

Prognosis.- 1 — The life of the patient appears to be in no danger from the 
illness, but at the same time his chances of recovery are small. Little is 
known as to the course of the disease in the child, but none of Dr. Gee's 
cases were influenced by treatment in the slightest degree. 

Treatment. — Erb recommends the galvanic current applied principally 
to the spine, but also to the affected limbs, and the application of cold 
compresses. Drugs appear to have but slight influence on the disease. 



SPASMODIC SPINAL PARALYSIS— TREATMENT. 383 

In a case of recovery reported by Von der Velden — in a man aged twenty- 
seven — bromide of potassium, belladonna, and morphia bad no beneficial 
influence ; indeed, the latter seemed to increase the number and intensity 
of the attacks. Chloral, however, was useful in moderating the spasmodic 
attacks when they were at their worst, and improvement began to be man- 
ifested while the patient was taking the double salt of gold and sodium. 
In Dr. Gee's cases hemlock, belladonna, Calabar bean, and strychnia — the 
two last hypodermically — were used in turn, but without the slightest 
benefit. 



CHAPTER XVIII. 

PSETJDO-HYPERTROPHIC PAEALYSIS. 

This singular form of paralysis, in which extreme feebleness of the muscles 
is combined with an appearance of extraordinary development and vigour, 
was first studied and described by Duchenne, of Boulogne. Almost at the 
same time, however, Dr. Edward Meryon, in England, had published some 
interesting particulars of four boys in the same family who were all 
affected with what appears to have been hypertrophic paralysis, although 
the author at the time was of opinion that the disease was identical with 
progressive muscular atrophy. Many cases have since been placed upon 
record, and there must be few children's hospitals which have not at 
one time or another had an example of the disease within their walls. 

Causation. — Of the etiology of the infirmity nothing is known. It is in 
the large majority of cases confined to the male sex. In Dr. Meryon's 
first series of cases, above referred to, all the boys (four) of the family suf- 
fered from it, while the eight girls escaped. This fact also illustrates 
another tendency of the disease, viz., its proneness to attack several mem- 
bers of a family. Two, four, and more children of the same parents have 
been known to be affected, and Dr. Meryon has referred to a striking 
instance in which eight brothers all died of the disease. This tendency seems 
to point to a hereditary element in the etiology of the infirmity. In investi- 
gating this question it is not enough, as Dr. Gowers has pointed out, to 
ascertain merely the health of the parents. Females are rarely affected by 
it, and males, the subjects of the disease, usually die at or soon after 
puberty. Therefore the tendency must be searched for amongst the 
collateral branches of the family. Such evidence is generally found on the 
side of the mother, and instances of the disease in some members of her 
family can be discovered sufficiently often to determine positively the fre- 
quent existence of this one-sided inheritance. 

The disease appears to be limited to childhood, and, indeed, is often 
congenital, the first symptoms manifesting themselves during infancy or 
shortly after that period. It seldom begins after the sixth year. 

Morbid Anatomy. — No morbid changes have as yet been discovered in 
any part of the nervous system to account for the disease, but the changes 
in the affected muscles themselves are sufficient to explain the phenomena 
of the affliction, and especially the apparent inconsistency between the 
unusual size of the muscles and their remarkable want of power. 

In the muscles the morbid process consists in an overgrowth of the 
interstitial connective tissue between the fibres. The nucleated fibrous 
tissue and the fat cells gradually increase in quantity and compress the 
muscular fibres. These under the pressure become narrower, and their 
strise farther apart, although still distinct; afterwards the striations become 
indistinct, and the fibres dwindle and eventually disappear, leaving the 



PSEUDO-HYPEETEOPHIC PAEALYSIS— SYMPTOMS. 385 

empty sarcolemma sheath running by the side of the fibrous bundles and 
proliferated fat cells. 

If the fat is greatly increased in quantity, the muscles on section may 
have the appearance of a fatty tumour in which no sign of muscular red- 
ness is visible to the naked eye. Under the microscope the fibres are seen 
to be separated by fat cells, but it is not common to find fatty degeneration 
of the muscular fibres themselves. 

Symptoms. — The earlier symptoms are very apt to escape notice as they 
have no distinctive character. They consist merely in weakness of certain 
muscles, usually those of the lower limbs, and sometimes of the back. If 
the disease begins in early infancy, before the time for walking has arrived, 
the child is noticed to be heavy to lift, and to want the resj^onsive 
" spring " which is so marked a feature in the healthy infant. In such a 
case it is late before he acquires the power of walking. If he has been 
able to walk before the disease begins, he very quickly gets tired, and 
shows a curious unsteadiness when on his legs. He can be thrown off his 
balance by a slight push, and when on the ground rises again with diffi- 
culty. When the weakness of the muscles has reached a certain degree, 
the child is forced to assume a characteristic attitude. In standing he 
separates his legs widely, and throws his shoulders backwards so as to 
exaggerate the antero-posterior curve of the lumbar spine. Consequently 
his belly is protruded, and, in a marked case, a vertical line dropped from 
the back of the neck falls clear of the buttocks. This attitude is the con- 
sequence of weakness of the extensors and flexors of the hip and the exten- 
sors of the knee — the muscles which maintain the body upright in stand- 
ing. The child, feeling these to be insecure, tries by separating his feet to 
enlarge his base, and as, owing to the weakness of the extensors of the hip, 
the pelvis is inclined unnaturally forwards, he throws his shoulders back- 
wards so as to keep the centre of gravity in the normal position. As he 
walks he still continues to separate his feet widely, and he sways his 
body from side to side so as to keep the centre of gravity over the foot 
upon which the weight of the body is resting. 

After a certain number of months, or, according to Duchenne, a year has 
elapsed, changes can be noticed in the muscles, and the weakness becomes 
more marked. The calves of the legs become enlarged, so as to give the 
appearance of unusual vigour, and generally a similar hypertrophy affects 
other muscles as well. The gluteal muscles, the muscles of the thighs, 
the posterior muscles of the spine, the deltoids, and sometimes almost all 
the muscles of the trunk and limbs may share in this enlargement. If 
the muscles do not become hypertrophied, they usually waste, and this 
diminution in size of some muscles renders more striking the extraordi- 
nary hypertrophy which affects other muscles in their neighbourhood. 

As the weakness of the muscles goes on progressively increasing, the 
characteristic attitude and gait become more and more marked. At the 
same time any slight extra strain put upon the muscles in the performance 
of certain acts increases the difficulty to such a degree that the child is re- 
duced to some very curious expedients in order to accomplish them suc- 
cessfully. Thus, in rising from a chair, he endeavours to assist the 
extension of the knee-joint by placing a hand on each femur just above 
the knee. By this means, especially if at the same time he bend forwards, 
he transfers a large part of the weight from the extremity (the hip) of a 
lever whose fulcrum is at the knee to a part of the lever close to the 
fulcrum ; or, even, if the body is bent forwards sufficiently to throw the 
centre of gravity in front of the knees, actually uses the weight to be 
25 



386 DISEASE IN CHILDREN. 

moved as a motor power to effect the straightening of the knee-joint. 
Again, in extending the hip-joints the patient begins by placing his hands, 
as in the former case, just above the knee, and then moves the hands 
alternately higher and higher until the straight position is arrived at. 

For some time the muscles retain sufficient power to carry the patient 
at a moderate pace along a level surface ; but he cannot jump, and in 
mounting the stairs he is forced to do so on his hands and knees. If told 
to get up from the ground, the child can only obey by going through a 
series of elaborate manoeuvres, all calculated to relieve or assist the 
weakened muscles. As Dr. Growers describes the process, the patient, 
being on all fours, keeps his hands on the ground, and stretches the legs 
out behind him far apart. Then, still keeping the body supported chiefly 
by the hands, he manages by shuffling backwards on the toes to get the 
knees extended. The body is thus supported by the hands and feet all 
placed as widely apart as possible. Next, the hands are alternately moved 
backwards along the ground so as to bring the larger portion of the 
weight of the trunk over the legs. Then, one hand is placed on the knee, 
and a push with this, and with the other still on the ground, is sufficient 
to enable the extensors of the hip to bring the trunk into the upright po- 
sition. In many cases the child cannot rise at all unless near to some 
piece of furniture, by means of which he can gradually hoist his trunk up- 
wards with his hands. 

As the paralysis extends the patient gets more and more helpless ; and 
when the upper limbs become affected, as usually happens after a few 
years have elapsed, his condition is very distressing. 

The affected muscles do not always increase in size. Sdmetimes they 
waste, and the hypertrophy and atrophy are irregularly distributed. Usu- 
ally many more muscles are wasted than are enlarged. The hypertro- 
phy is apt to affect by preference certain muscles. The muscles of the 
calf, the vasti of the thigh, the glutsei, the infra spinati, and the del- 
toids are often enlarged. On the contrary, the muscles on the front of 
the leg are more usually wasted, and wasting is also more common 
in the latissimus dorsi and the sterno-costal portion of the great pectoral 
muscle. In the arm the biceps and triceps may be enlarged, but the 
muscles of the forearm are rarely affected. Sometimes the temporals and 
masseters are hypertrophied. In some rare cases the muscles, before they 
begin to enlarge, have been noticed to be smaller than natural. 

This form of paralysis is not accompanied by any general fever, but 
Dr. Ord has noticed a higher temperature in the leg where the muscles 
are hypertrophied than in the corresponding thigh. This, however, is not 
a constant phenomenon. At first the muscles respond normally, or nearly 
so, to the galvanic current, both interrupted and continuous ; but when 
greatly wasted, the muscular response is weak, or even absent. The knee 
reflex is usually notably diminished. Sensation, however, is unimpaired, 
and there is perfect control over the bladder and sphincter. 

Towards the end of the disease contraction and shortening may occur 
in certain muscles — usually in those the opponents of which are exces- 
sively enfeebled. This is a phenomenon which is seen in other forms of 
paralysis, and its mechanism is discussed elsewhere (see page 375). There 
is, however, one form of contraction which has been said by Duchenne to 
be a constant symptom of pseudo-hypertrophic paralysis. This is seldom 
noticed before the end of the sixth year. It takes place at an earlier 
period than the ordinary paralytic contractions, and occurs as a conse- 
quence of shortening in the length of the diseased gastrocnemii. These 






PSEUDO-IIYPEETEOPHIC PAEALYSIS — DIAGNOSIS. 387 

muscles draw up the heel so that the patient cannot press this part of his 
foot to the ground, and as the contraction increases a talipes equinus 
is developed. The deformity is usually symmetrical When combined 
with the muscular weakness it makes walking very difficult. Consequently 
there is nothing to oppose further contraction, and the extension of the 
ankle soon becomes extreme. 

The disease may be associated with idiocy and mental feebleness, as 
appears from some cases published by Dr. Langdon Down, and with epi- 
lepsy and other forms of cerebral deficiency and disturbance. But these 
do not appear to be an essential part of the disease ; indeed, in most re- 
corded cases the cerebral functions have been unimpaired. 

The coarse of the disease is fairly constant, and the age at which the 
illness reaches its fatal termination varies, as a rule, according to the age 
when the symptoms first appeared. Thus, if the symptoms have occurred 
in infancy, the power of standing is lost about the tenth or twelfth, and 
death ensues between the fourteenth and eighteenth years. If the early 
symptoms have been delayed until the sixth or eighth year, the patient is 
less incapacitated by the time puberty is readied, and may live to the age 
of nineteen or twenty, or even longer. Still, sometimes the disease runs a 
shorter course, and it may happen that although late to appear the symp- 
toms develope rapidly, and the patient quickly loses all power of support- 
ing himself upright. Even in the fatal cases death is only indirectly the 
consequence of the hypertrophic disease. When the muscles of the chest 
become attacked, the inspiratory power is greatly enfeebled, and any acci- 
dental lung complication soon assumes alarming proportions. In fact, it 
is usually to bronchitis or pneumonia that the fatal termination is to be 
directly attributed. 

Diagnosis. — Inordinate size and firmness of muscle combined with ex- 
treme weakness and unsteadiness, developing slowly, and becoming grad- 
ually more and more marked, without cerebral symptoms, impairment of 
sensation, or weakness of the bladder or rectum, are the most characteristic 
features of the disease. The peculiarities of attitude and gait are also to 
be noted. The position of the child, as he stands with his feet widely apart, 
his abdomen protruded and his shoulders thrown back, his rolling gait in 
walking, and his method of helping to straighten the knees by pressing 
with his hands upon the femur just above the joint, must not be overlooked. 

Hypertrophy of the muscles is not always present. Largeness and 
hardness of the calves are very characteristic, but scarcely any less charac- 
teristic are their contraction and wasting with drawing up of the heels. 
Dr. Gowers attaches great importance in diagnosis to the increased size of 
the infra-spinatus muscle, with wasting of the latissimus dorsi and lower 
part of the pectoralis major. 

There is little difficulty in distinguishing the disease from infantile 
spinal paralysis, which comes on quite suddenly, in which the paralysis, at 
first general, quickly limits itself to certain muscles, faradic contractility 
early disappears, and wasting is rapid and extreme ; nor from spasmodic 
spinal paralysis, in which spasm is a marked feature, with great rigidity of 
joints and exaggeration of the tendinous reflexes. It is more difficult to 
decide between this affection in its early stage and cerebellar turaour, or 
the indefinite beginning of intracranial disease in well-nourished children 
— cases where sometimes all that can be detected is that the child is giddy 
and falls about. Still, in pseudo-hypertrophic paralysis the attitude is un- 
mistakable, and the way in which the child rises from the ground can 
scarcely be misinterpreted. Progressive muscular atrophy is so excessively 



388 DISEASE IN CHILDKEN. 

rare in childhood that it may be left out of consideration. It differs mark- 
edly from the disease we are considering by being never attended by 
muscular pseudo-hypertrophy, and by invariably beginning in the upper 
part of the body. In a child seen by Duchenne it began in the face. 

Prognosis. — When the disease is confirmed we can scarcely hope by 
any remedial measures to stop the progress of the muscular change. If 
the patient be seen at an early period of the attack, before any enlargement 
of the muscles has been noticed, treatment is said to afford more hope of 
success. In estimating the chances of a lengthened course we must take 
into consideration the period at which the first symptoms were noticed, 
the rate at which the affection is advancing, and the age and sex of the 
patient. According to Dr. Gowers, the progress of the disease appears to 
be often related to the process of growth ; therefore the less the muscular 
change has advanced at a period when the growth of the body is com- 
pleted, the greater the likelihood that the disease will become stationary. 
As a rule, when it appears late it advances slowly. Therefore in the most 
favourable cases the affection has appeared late, and has advanced but little 
at the time of full growth of the body. As these conditions are more often 
found united in girls than in boys, the female sex is in itself a favourable 
element in the prognosis. 

Treatment. — There is little to be done in the way of treatment. Du- 
chenne states that he has succeeded in arresting the disease in two cases by 
means of faradism, kneading and shampooing the muscles, and the use of 
baths. Benedikt recommends the continuous current. Arsenic and phos- 
phorus given internally have been thought to be useful by some. Supports 
to the spine are of service when there is great weakness of the back, and 
in cases of marked contraction of the calf muscles the tendo Achillis has 
been divided with great temporary advantage. 



CHAPTER XIX. 

IDIOCY. 

Mental feebleness or deficiency, either congenital or acquired, is, unfortu- 
nately, a far from uncommon defect in childhood. The subject is an im- 
portant one to the physician, for although he may not be called upon to 
treat such cases, he is often consulted upon the chances of recovery, and 
every degree of feebleness of mind, but especially the milder forms of im- 
becility and mere backwardness, may be brought under his notice. 

Causation.— Heredity plays a very important part in the production of 
mental deficiency in the child. Imbeciles, fortunately, do not often many, 
but a tendency to neurotic disease, such as insanity, epilepsy, etc., in the 
parents has a powerful influence in inducing feebleness of mind in their 
offspring. Dr. Langdon Down, from careful investigation in two thousand 
cases of idiocy, f ound that in no less than forty-five per cent, a well-marked 
neurosis existed in the families of one or both the parents. 

The scrofulous diathesis has been said to favour the occurrence of 
idiocy ; and there is no doubt that a large proportion of imbeciles are the 
subjects of scrofulous cachexia. Still, mental feebleness is not a necessary 
part of the diathetic disease ; indeed, children of very evident scrofulous 
constitution often display exceptional intelligence. The explanation may 
probably be that the scrofulous habit tends to foster the influence of a 
neurotic tendency, and that the latter will operate with greater force and 
certainty in cases w r here it is associated with malnutrition in any of its 
forms. So, also, consanguineous marriages, and intemperance on the 
part of the parents, are well-known agencies in giving increased energy to 
any hereditary neurosis or morbid taint. Therefore any instability of the 
nervous system w T hich may exist in such persons is likely to develope into 
a new and more striking phase in their offspring. 

The above influences are influences of a very general kind, and all 
children born of the same parents must be equally subject to them. Idiots 
are seldom "only" children; indeed, statistics show that they are often 
born of more than ordinarily prolific parents whose other children exhibit 
no sign of intellectual deficiency. This being so, we must look for other 
and more special causes for their mental failing. 

These special causes may either operate during gestation, at the time 
of birth, or after the child is born. 

It is a suggestive fact that out of the two thousand cases investigated 
by Dr. Langdon Down no less than twenty-four per cent, we're primiparous 
children. The cause of this undue preponderance in the first-born is no 
doubt owing, as Dr. Down points out, not only to the exalted emotional 
state of the mother during her first pregnancy — a state in which all causes 
of disturbance would naturally operate with exceptional force, but to the 
tediousness of the first labour, which is apt to give rise to a condition of 
suspended animation in the infant. Dr. Down's statistics well illustrate 



390 DISEASE IN CHILDPwEN. 

the force of these influences. Twenty per cent, of the idiots were born 
with well-marked symptoms of suspended animation ; and of idiots born 
this condition, and only resuscitated by assiduous labour, no less than forty 
per cent, were first-born children. Bearing upon the same matter is the 
fact of the preponderance of male over female idiots, for the larger head 
of the former would increase the difficulty of parturition, and conduce to 
the state of suspended animation which experience shows to be so hurtful 
to the cerebral functions. 

Whether the mother be a primipara or not, powerful emotional shocks 
are injurious, and may act very unfavourably upon her offspring. In no 
less than thirty-two per cent, of Dr. Down's cases there was a well-founded 
history of mental shock. Again, excessive sickness, by impairing the 
mother's nutrition, is also calculated to exercise an unfavourable influence 
upon the intellectual development of her infant. Dr. Langdon Down 
found in ten per cent, of his cases a history of marked and persistent 
vomiting. 

After the child is born other causes come into operation. The mental 
incapacity may develope at a constitutional crisis, such as the time of the 
first or second dentition, or of puberty ; the amount of brain-power which 
had been previously sufficient for the wants of the economy failing to carry 
it through such critical periods of development. Masturbation in these 
cases may be an important factor in determining the break-down. Again, 
accidental causes may come into operation in a child who had never shown 
symptoms of mental failure. Thus, he may become idiotic as a result of 
repeated convulsions or epileptic attacks, of chronic hydrocephalus, of 
injuries or blows upon the head, of some inflammatory condition occur- 
ring as a complication of acute disease, and of impairment of the senses 
interfering with the development of the intellectual faculties. 

One form of idiocy — cretinism — is endemic in certain parts, although it 
may also occur sporadically. 

Morbid Anatomy. — In most cases of idiocy — in all in which the mental 
deficiency is congenital — the brain is small and often imperfectly developed 
as well. There may be great simplicity in the convolutions, approaching 
to the condition of the brain in the anthropoid apes ; there may be atrophy 
of the medulla oblongata, and asymmetry of the base of the brain ; ab- 
sence of the corpora geniculata, the corpus callosum, or even, as was seen 
in a case recorded by Cruveilhier, the whole cerebellum ; the convolutions 
may be shrunken and the brain substance hardened. In other cases 
the child may be from birth the subject of chronic hydrocephalus. The 
brain is sometimes abnormally large, but may present no obvious change 
to the naked eye. Still, from the researches of Dr. M. Jastrowitz it 
seems that even in these cases careful microscopic examination may detect 
alterations in structure in the minute tissues of the brain, especially a 
persistence of anatomical elements which are normal in the embryo, but 
which ought to have passed into another form in the growing child. 

Again, there may be cranial as well as cerebral abnormalities. The 
sutures and fontanelles may undergo premature coalescence ; and if there 
be no compensation by unusually slow ossification at the base, allowing of 
greater expansion in that region, the entire cranium is well proportioned 
but very small, and profound disturbance of the growth of the brain is the 
consequence. If, however, there be basic expansion, a special type of 
physiognomical and physical development, which Griesinger has described 
as the "Aztec" type, results. When the base of the cranium is shortened 
by ossification, it is indicated to the eye by malformation of the face. We 



>rn 



IDIOCY — VAKIETIES— SYMPTOMS. 391 

find the eyes widely separated, a prominent ridge to the nose, and high 
and prominent cheek-bones. There may be actual microcephalus, and the 
development of the pons and medulla is often affected. Usually, however, 
a certain compensation is found in extension of the skull in different di- 
rections, producing many varieties in the shape of the cranium, and allow r - 
ing of more or less expansion of the brain in the upper regions. 

Varieties. — Many different methods of classification of idiots have been 
proposed. There is the psychical classification of Esquirol, in which the 
idiot is arranged into three classes, according to the degree of speech of 
which he is capable. The first class includes those who use merely words 
and short phrases. The second class consists of those who can articulate 
monosyllables or certain cries. To the third class are referred those who 
are capable of articulating neither w T ords nor monosyllables. 

Idiots may be also arranged into three classes according to the devel- 
opment of nervous function. A first class exhibits nothing beyond the re- 
flex movement known as excito-motor. In a second class the reflex acts 
are consensual or sensori-motor, including those of an ideo-motor or 
emotional character. In a third class we see manifest volition ; their ideas 
produce some intellectual operations and consequent will. 

Another classification is that suggested by Dr. Langdon Down, accord- 
ing to their resemblance to ethnological types — the Caucasian, Ethiopian, 
Malay, and Mongolian. Dr. Down has also proposed a good practical 
classification, based on etiology, into 1, Congenital ; 2, Developmental ; 3, 
Accidental. 

The congenital group embraces all those cases where the signs of 
mental deficiency date from birth, and includes as subdivisions : a, Stru- 
mous ; b, Microcephalic ; c, Macrocephalic ; d, Hydrocephalic ; e, Eclampsic ; 
f, Epileptic ; g, Paralytic ; h, Choreic. 

The developmental idiot is a child who is born with a fair amount of 
brain pow 7 er, but who breaks down at one or another of the developmental 
crises — at the first or second dentition or at puberty. Such children lose 
the power of speech and their minds seem to give way at one of these evo- 
lutional stages. The group includes as subdivisions : a, Eclampsic ; b, 
Epileptic ; c. Choreic. 

In accidental idiocy the mental break-down is the consequence of some 
shock or traumatic injury, or disease operating upon a healthy child born 
free from any tendency to intellectual deficiency. This group includes : 
a, Traumatic ; b, Inflammatory ; c, Epileptic. 

Symptoms. — In cases of congenital idiocy the baby begins from an 
early age to show that he is not the same as other infants. The develop- 
ment of his faculties does not run the ordinary course. He cannot support 
his head like another child, but lets it hang back on his nurse's arm. 
Then, he takes little notice. A healthy infant will often recognise his 
mother by the sixth week ; but long after that period the idiot child shows 
no recognition of faces. His eyes have a vacant look, seem incapable of 
fixing upon an object, and often oscillate from side to side (nystagmus). 
Again, he does not smile or laugh as a child will do whose mental develop- 
ment is advancing naturally ; and manifests a strange inability to grasp 
with the hand. A healthy child's fingers curl round any object presented 
to them at a very early age, but the idiot infant seems to have no power 
of making any use of his hands. Moreover, when danced up and down, 
his muscles do not contract in sympathy with the movement. He seems to 
derive no pleasure from the exercise, but remains a dead weight like a 
heavy doll. 



392 DISEASE IN CHILDREN. 

The head is usually noticed to be peculiar in shape from an early age. 
It is often high in the crown, and perhaps the fontanelles are closed, or 
nearly so, at the end of six months. Again, from the investigations of Dr. 
Langdon Down it appears that a high-vaulted palate — the V-shaped palate 
— with a very narrow transverse diameter is a common deformity of the 
congenital idiot. The tongue is often corrugated with transverse furrows, 
and sometimes is not completely under command. It hangs out of the 
mouth, and the child dribbles in an unusual degree even for a baby. The 
teeth are commonly late in being cut and often appear irregularly. 

At twelve months old, when the child should be able to stand, or should 
at least crawl on the floor and try to raise himself on to his feet, he lies 
just as he is put down, without an attempt to move himself along. Often 
he does not leam to walk until he is three or four years old. It is also 
difficult to teach him cleanly habits, and he remains infantine in his 
ways at'an age when other children have long been taught decency and 
order. 

When idiocy is congenital, growth and development are impaired as 
well as mental power, and the general health is far from satisfactory. The 
patient is stunted in his stature and looks younger than his age. The cir- 
culation is often feeble, and the temperature a degree or two lower than 
that of health. The feet are cold. The heart is frequently small and weak 
in structure, and there may be an open foramen ovale or other congenital 
deficiency. Often other malformations are seen, as imperfect development 
of one or more fingers, a club foot, or some strange shape of the ears. 
Such children may show signs of rickets, and are not seldom of decidedly 
scrofulous constitution. As they grow up, an unpleasant smell is often 
noticed about the body and breath. In bad cases automatic movements 
are present ; chorea and epileptic fits are common complications, and the 
senses are frequently dull. 

Griesinger describes two special varieties of idiots — the apathetic and 
the excited. 

The apathetic class are awkward, clumsy, and disproportioned, with re- 
pulsive, old-looking features. From their torpor and impassiveness they 
seem to be in a dreamy state. Their expression is either brooding and 
melancholy, or vacuous and indifferent. 

The excited or agitated class are just as stupid as the other, but are 
quick in movement and irritable, passing rapidly from one impression to 
another, and quite incapable of fixing anything on their mind. 

Between these two principal groups there are many intermediate va- 
rieties. 

There is one form of idiocy, endemic in some countries, sporadic in 
others, which merits a separate description. This is cretinism. The fee- 
bleness of intellect from which cretins suffer is combined with striking 
peculiarities of bodily structure. The condition is always congenital. It- 
is not hereditary in the ordinary sense, although where the other conditions 
inducing the disease prevail, the child will become cretinous more certainly 
if born of cretinous parents. The disease has been said to be dependent 
upon the general causes of ill health — bad air, bad water, imperfect drain- 
age, insufficient light and poor food, combined with the use of water 
loaded with calcareous salts. It may therefore prevail in any quarter of 
the world where these conditions are found ; and certain close valleys in 
the Alps, Pyrenees, and Himalaya mountains are especially notorious for 
the number of cretins born in them. The value of these causes in produc- 
ing the condition has, however, been called in question. Perhaps it is best 



IDIOCY— CRETINISM— SYMPTOMS. 393 

to say that nothing positive is known with regard to the etiology of the dis- 
ease. Whatever the cause may be, it appears to be also the cause of goitre, 
for cretinism and goitre are frequently associated. It has been said that act- 
ing feebly the causes produce goitre" acting strongly they give rise to cre- 
tinism ; but even this is hypothesis. Cretins are not invariably goitrous. In- 
deed, in sporadic cases, such as occur from time to time in London, it is not 
uncommon to find that the thyroid body is absent. In two cases which came 
under my own notice no trace of a thyroid body could be detected. It is 
in places where cretinism is endemic that it is usually complicated with 
goitre ; but even in such neighbourhoods the goitre is not confined to cre- 
tinous subjects ; and the area over which goitre is endemic is much larger 
than that in which cretinism is prevalent. 

Virchow's researches have done much to elucidate the chief feature of 
cretinism. According to this authority, it consists in an abnormal tendency 
to ossification and coalescence ■ of the three bones which represent the 
bodies of the last three cranial vertebrae, viz., the basilar process of the oc- 
cipital bone, the post-sphenoiclal, and the prse-sphenoidal bones. In the 
normal condition ossification in these bones goes on slowly from behind 
forwards, and traces of unossified cartilage may be found as late as the 
thirteenth year. During the whole of this time the cartilaginous parts 
are still growing, and allow of expansion of the base of the skull and en- 
largement of the cranial cavity in proportion to the wants of the growing 
brain. In the cretin, in whom ossification in these parts takes place early, 
the base of the skull cannot elongate ; the distance from the crista galli to 
the occipital foramen remains short ; the corresponding parts of the brain 
are imperfectly developed, and the form of the skull is modified. Moreover, 
the bones of the skull are in many cases greatly thickened and the fora- 
mina narrowed. The bones of the limbs frequently show the same ten- 
dency to rapid ossification, and the shafts form early union with their 
epiphyses. Consequently, the growth of the bones is imperfect, The 
brain undergoes many modifications. Important parts, such as the gan- 
glia at the base, are often ill developed, the medulla oblongata may be 
small, and the fissure of Sylvius shallow and ill defined. 

The physical and mental characteristics of the cretin are well illustrated 
by a case which was under my care in the East London Children's Hospi- 
tal. The patient was a little girl, aged seven years, who had come of a 
healthy family on both sides. She had five perfectly healthy brothers and 
sisters. The family lived in Shadwell, in the neighbourhood of the hospi- 
tal. The child was said to have been a fine baby at birth, but as the 
months passed no teeth appeared, and she showed no inclination to stand 
or even crawl upon the iloor. She generally seemed very dull and apa- 
thetic, but sometimes brightened up and became more lively. 

At seven years of age, when admitted into the hospital, she was barely 
thirty-one inches in height. She looked very broad for her height, and 
weighed thirty-one pounds eight ounces. Head large, nineteen inches in 
circumference, covered by long, sparse, coarse hair of a- dull reddish brown 
colour ; features large and coarse ; bridge of nose depressed ; eyes wide 
apart ; lips thick and pouting ; mouth generally kept half open ; teeth 
square, as if worn down ; tongue large ; eyes gray and dull-looking ; expres- 
sion vacant as a rule, bat sometimes brightening up when amused with 
a doll or ball. No trace of a thyroid gland could be discovered ; above 
each clavicle was a semi-globular mass, about the size of a Tangerine 
orange. The skin was rather dry and shrivelled-looking, with a yellowish 
tint. The chest was well formed. There was no beading of the ribs or 



394 DISEASE IN CHILDREN. 

other sign of rickets. The tibiae were somewhat bowed outwards, but the 
limbs were massive and the flesh firm. 

The child smiled when spoken to, and could say the word " doll," but 
appeared to apply it indifferently to all kinds of toys. She could not walk, 
but crawled about on her hands and feet, keeping her knees raised. 
When she reached a table or bed, she would raise herself into an upright 
position with her hands and stand holding by it. The child passed urine 
and faeces in the bed. Her temperature was habitually subnormal. 

The soft globular lumps above the clavicles are frequent in the sporadic 
form o£ cretinism. In Mr. Curling's cases they were found after death to 
consist of fatty tissue. 

In another case which came under my notice the patient, who had the 
appearance of a child, was really over seventeen years of age. His height 
was half an inch under three feet, his weight, thirty-six pounds fourteen 
ounces. He had all the physical peculiarities described in the previous 
case, but was more intelligent and cleanly in his habits. He could answer 
simple questions as to his food intelligibly. He had the same fatty 
masses in the supraclavicular hollows, and no thyroid body could be 
felt. His genitals were those of a child, and he never manifested any 
sexual propensities. 

The symptoms of cretinism seldom appear before the sixth or seventh 
month. The head is usually large, for cretins never belong to the micro- 
cephalic type. The palate is often flat, and not highly arched, as in ordinary 
congenital idiocy. These patients are usually quiet and good-tempered, 
although subject to occasional fits of passion. Their senses are often dull, 
and they endure great cold and heat without apparent discomfort. It is, 
however, one of the characteristics of idiots generally that their senses are 
obtuse : they can often bear pain with singular indifference ; their taste is 
not uncommonly impaired or perverted, and sometimes they have but a 
faint sense of smell. Often their sight is defective from congenital cata- 
ract, or imperfect sensibility of the retina, or hypermetropia with diminished 
accommodation ; but unless they have suffered from disease of the ear, their 
hearing is usually of normal acuteness. 

The mental condition of idiots has many varieties. In the lowest form 
there is complete apathy and torpor ; no power of attending to or even 
recognising their own wants, and no capacity to speak or to understand 
words spoken to them. Such beings can only make unintelligible noises. 
They have not the slightest power of will, and seem to have little power of 
originating a movement, but often repeat mechanically some automatic 
motion of the head, the body, or a limb. 

At the other end of the scale is mere feebleness of mind. Such chil- 
dren can be taught to read, and are capable of great improvement by kind- 
ness and perseverance. Even in the higher class of idiots speech is 
usually defective, partly from malformation of the mouth ; partly from 
want of co-ordination of the lingual muscles ; but chiefly, no doubt, from 
the poverty of their vocabulary, and the small stock of words to which they 
attach any definite meaning. In all the severer forms of idiocy no attempt 
at speech is ever made ; and, as Griesinger observes, the idiot who does 
not speak has no internal idea of speech, and is therefore "deficient in the 
most essential element in the mechanism of abstraction." 

Idiocy has been described as a fixed infantile condition, and the idiot 
has been compared, as regards intelligence, with a healthy child of so many 
months or years of age. An idiot, however, is not merely a backward 
child. With him volition is feeble or quite absent ; and he has little 



IDIOCY — DIAGNOSIS. 395 

imagination or power of abstract thought. Therefore, although his actual 
degree of intellectual development may correspond with that of the younger 
child, there is a something still wanting, which if wanting in the child with 
whom he is compared would occasion very serious anxiety. Sometimes 
one faculty is developed in idiots to the exclusion of all others. In all 
treatises on this subject instances are given showing remarkable aptitude 
for music, drawing, and reckoning ; also for various forms of mechanical 
construction as carpentering, model-making, etc. 

Diagnosis. — Idiocy must be distinguished from mere backwardness, 
and also from cases where the development of the mental faculties suffers 
through deficiency in the sense of hearing. 

Mere backwardness, even when present in a marked degree, is far re- 
moved from idiocy. The class of backward children presents many points 
of interest. The delay in development is usually physical as well as men- 
tal. They are small but not usually deformed ; and there is no symptom 
of disease of brain or disorder of mind. They are simply backward chil- 
dren in whom progress of every kind takes place very leisurely. Instead of 
learning early to walk, and picking up words and ideas with the quickness 
of a healthy child, they are slow to walk, slow to talk, slow to quit the 
habits and helplessness of the baby for the decency and independence of 
later childhood. Still, they do not remain stationary like the idiot ; they 
do learn, although slowly ; and with patience can be taught in time much 
that forms the education of a child of ordinary capacity. Backward chil- 
dren, however, sometimes become idiotic. If they happen to be also epi- 
leptic or addicted to self-abuse, they may gradually become duller and 
duller and fall into a state of complete idiocy. 

In all cases of backwardness, especially of lateness of talking, with ap- 
parent dulness of mind, the state of the hearing should be inquired into. 
A child who hears imperfectly is always slow in acquiring the power of ar- 
ticulation ; and besides, as Dr. West has pointed out, his difficulty with 
this defect of keeping up intercourse with other children makes the patient 
dull, suspicious, and unchildlike. 

Idiocy, when confirmed, is of interest chiefly to the specialist. The ordi- 
nary practitioner is most concerned with the early symptoms of mental fee- 
bleness, as this is seen in the infant. Nothing is commoner than for the 
family physician to be consulted because the baby "does not seem to take 
notice." 

In a healthy infant the senses come into play in the following order : 
Sight is the earliest to manifest itself. A fortnight after birth the infant's 
eyes should follow a light, as that of a lamp ; and at the end of a month 
or six weeks he is often able to recognise his nurse and will smile when 
she approaches. During the first few weeks babies often squint, especially 
when looking at a near object. Later they become more expert in focus- 
ing their eyes to suit various distances. 

The child seldom gives evidence of hearing sounds before the third 
month, although Darwin states that his infants started at sudden noises 
when under a fortnight old. Babies do not recognise voices until after 
the fourth month, and it is the eighth or ninth month before they begin to 
recognise objects by name. 

With regard to movements : a child of two months of age will raise 
his head from the pillow ; and after the third month will begin to use his 
hands and to toss up his head. At this time (the third month) he can 
support his heal well. It is usually the ninth month before the child 
" feels his feet," i.e., presses his soles to the ground when held to the 



396 DISEASE IN CHILDREN. 

floor. He should walk some time between the tenth and the eighteenth 
month. 

A healthy infant should keep his tongue within his mouth from the 
earliest age. His fontanelle should not close before the eighteenth month, 
nor be completely ossified before the end of the second year. 

' The faculty of speech is acquired much more quickly by some children 
than by others. Most babies will begin to say words after the end of the 
first year, and many can talk freely by the end of the second. 

It is seldom before the end of the sixth month that any suspicion is felt 
that all is not right with the infant's mental development. Then it is 
usually the vacancy of his expression, the absence of any smile to greet his 
mother's approach, some peculiarity in his way of taking food, and the 
dead weight of the child as he lies with his head back in his nurse's arms 
that first excites the anxiety of the parents. In such cases we notice the 
weakness of the muscles of the back and neck, and their inability to sup- 
port the head or keep the body erect for a moment, the nystagmus, the 
vacant look in the eyes, which never seem to fix upon an object, and can- 
not be made to follow it when it is moved before them, the abnormal flow 
of saliva from the mouth, and the passiveness of the child's hand when a 
finger is placed in it — so different from what occurs with the healthy baby 
who at once squeezes anything which touches his fingers. On inquiry we 
find either that the child is always whining, or that he is strangely silent 
and pays no attention to sounds which please other infants of his age ; 
also, perhaps, that he takes the breast or bottle very slowly, and often makes 
a curious choking noise at the back of his nose. In such cases we gener- 
ally find that the palate is narrow and highly arched (the V-shaped palate) ; 
that the head is small and of a curious shape — unsymmetrical, or very high 
and narrow in the crown ; that the fontanelle is excessively small or quite 
closed ; that the hands and feet tend to be cold ; that the muscles feel 
flabby, and on examination we can sometimes discover a congenital heart 
complaint, a club foot, or some other form of congenital deformity. Dr. 
Langdon Down has drawn especial attention to the appearance and posi- 
tion of the ear. A helix or the lobule may be quite absent, and the pinna 
is often planted farther back in relation to the head and face than in the 
healthy child. Dr. Down also directs that the position of the eye, as to 
obliqueness, as well as degree of separation, should be noted, as there is 
often an approach to the ethnical variety described by this physician as 
the Mongolian type. Also, that the integument about the eyes should be 
examined for semilunar folds of skin at the inner can thus (epicanthic 
folds), which are more common in feeble-minded infants than in the healthy. 

The cretin can usually be recognised without difficulty by his stunted 
growth ; his large head ; his depressed nose, with widely separated eyes ; his 
dull, heavy expression ; wide mouth, broad lips, and thick tongue ; his shriv- 
elled-looking tawny skin ; his heavy limbs and awkward walk. If the disease 
is endemic, there is probably a goitre ; if sporadic, we notice the curious 
fleshy elastic masses above the clavicles and the absence of a thyroid gland. 

Prognosis. — The most hopeful cases are those in which the defect is a 
congenital one ; the worst are those of accidental origin who bear in their 
faces and persons little trace of their infirmity. Paralysis or epilepsy, or 
other form of nervous instability, increases the difficulty of the case. So, 
also, general feebleness of health is a bar to improvement ; and profound 
scrofulous cachexia, or a weak heart and feeble circulation, render the 
patient less responsive to systematic training than another whose nutrition 
is more satisfactory. 



IDIOCY — PROGNOSIS — TREATMENT. 397 

Dr. Edward Seguin regards as favourable signs: Steadiness of the 
walk, which deviates little from the centre of gravity ; a hand firm without 
stiffness, and not disturbed by automatic movements — one which can take 
and leave hold at command ; an unimpaired state of the senses, especially 
a look which is easily called into action ; a command of the words, however 
imperfect or few, which the child may possess, so that they have a con- 
nected meaning and come out opportunely ; activity without restlessness ; 
willingness to obey ; sensibility to praise, and capability of returning as 
well as of receiving caresses. 

A contrary state of things must be looked upon as unfavourable. More- 
over, if some feelings of affection have been developed by kind parents, 
and are not followed by corresponding intellectual progress ; or if the 
idiocy is complicated by extensive paralysis, or worse, by epilepsy, the 
prognosis is very bad. 

Treatment. — In the treatment of idiocy our first care should be to attend 
to the general health of the patient, so that he may be put physically into 
as good a condition as he is capable of reaching, and afterwards to incul- 
cate volition and co-ordinated voluntary movement by careful physical 
training ; to attend to his moral education, and do what can be done to 
develop his intellect. 

It is very important that the idiot should be removed from the society 
of healthy children, whose games he cannot share, and whose companion- 
ship he cannot enjoy, to association with beings afflicted like himself, in the 
presence of whom he is not oppressed by a painful sense of inferiority. 
It is indispensable to the due progress of the feeble in mind that they 
should be received into asylums and establishments especially devoted to 
the treatment of such cases. In these every means can be adopted to 
counteract the scrofulous tendencies of which a large proportion of the 
patients are the subjects. The building can be erected at a suitable ele- 
vation on a porous soil of sand or gravel. The rooms and passages can be 
large, well ventilated, and suitably warmed. Moreover, a proper system of 
bathing and shampooing can be established to promote the healthy action 
of the skin and invigorate the feeble muscles. 

The dietary should be liberal, and presented in a form to suit the 
peculiarities of the patient, for many idiots cannot chew their food. Some, 
indeed, can only swallow it when it is placed far back on the tongue, so 
that it may come within the grasp of the pharyngeal muscles. 

Residence at a special training school, it is generally held, should begin 
when the patient is about seven years of age, unless the existence of con- 
stitutional disease, epileptic fits, or other complication requiring constant 
medical supervision necessitate earlier admission. The system of training 
can be divided into three branches : physical, moral, and intellectual. 

The physical training consists in careful education of the muscles by 
regular co-ordinated movements which bring the will into exercise, and 
substitute purposive acts for the aimless automatic motions which are so 
characteristic of the vacant mind. The exercises are graduated, and pass 
from the simplest movements to others more complex in character, so that, 
as Dr. Langdon Down observes, " the idiot builds up a series of co-ordi- 
nated voluntary movements which are applicable to the wants of daily 
life." 

Moral education teaches the child obedience, and encourages him to 
endeavour to win the approval and retain the affection of his teachers by 
doing what he is told is right, and avoiding what he is told is wrong. 

The intellectual education is based on a cultivation of the senses. 



398 DISEASE IN CHILDREN. 

Touch and feeling are trained to appreciate differences in the form of 
objects, beginning- with simple things and proceeding gradually to the 
more complex. Sight is cultivated by making the patient appreciate light 
and darkness, and accustoming him to match coloured counters or string 
coloured beads. So on with the other senses. Everything that is taught 
should be taught in the beginning in the simplest way, and we should 
make sure that the first fact has been thoroughly grasped before we pass 
on to the second. In this way the mind is educated through the senses, 
and in time by patience and perseverance astonishing results may be often 
obtained. 



|)art G. 
DISEASES OF THE ORGANS OF RESPIRATION. 



CHAPTER I. 

EXAMINATION OF THE CHEST. 



The affections of the lungs constitute a very important branch of the dis- 
eases of childhood. The study of these complaints must no doubt present 
peculiar difficulties, for persons who are fairly conversant with the ordinary 
maladies of early life will often profess their inability to understand them. 
In many cases an examination of the chest in a child cannot be carried 
through without much tact and management ; in others the utmost gentle- 
ness will not reconcile the patient to a procedure of which he only per- 
ceives the inconveniences ; and even in the most favourable cases the ob- 
server meets with peculiarities in the physical signs which in one unaccus- 
tomed to such youthful patients may give rise to considerable perplexity. 

In order to examine the chest of a child with success the patient must 
be raised up to a convenient height. If we stoop down to a child as he 
sits upon his nurse's lap, our own position is cramped and uncomfortable. 
Fully to appreciate minute deviations from a healthy state the attitude of 
the observer should be one of ease. In the case of an infant, to examine 
the front of the chest the child should be laid upon his back on a cushion 
placed upon the table. Some babies, however, cry at once when laid upon 
the back. In such cases the patient may be placed in a sitting position on 
the cushion supported by the nurse. When the back is examined the 
nurse should stand up and take the child on her left arm, so that his head 
and right arm hang over her left shoulder, and his left arm is loosely ap- 
plied round her neck. In this position the muscles of both shoulders are 
relaxed. An older child can be seated upon a table for examination. It 
is needless to say that in both cases the patient should be completely 
stripped to the waist. 

Much may be learned from mere inspection of the chest. In the case of 
an infant the points to which attention should be directed have already 
been referred to (see page 12). In children of four or live years old and up- 
wards we can often ascertain by this means the existence of a constitutional 
predisposition. In children of consumptive tendencies the lungs are small. 
As a consequence the thorax is forced to adapt itself to the size of its con- 



400 DISEASE IN CHILDKEN. 

tents. The shoulders are narrow and sloping ; the ribs are very oblique 
and the chest elongated ; and the scapulse project backwards like wings. 
The prominence of the shoulder-blades has given the name of " alar " or 
" pterygoid " to this variety of chest. In small-lunged children, and chil- 
dren with vulnerable chests, the thorax is often flattened anteriorly, so as 
to diminish the antero- posterior diameter. The flattening is due to yield- 
ing of the costal cartilages und,er the pressure of the atmosphere when the 
lungs are expanded in the act of inspiration. It is usually the consequence 
of narrowing of the air-tubes from catarrh of the mucous membrane. If 
we notice the shape of the chest to correspond to either of these types, we 
must examine the apices very caref ally for signs of disease. Moreover, 
in the treatment of even the simplest pulmonary derangement in such 
cases we must be careful to follow up any special medication by invigorat- 
ing measures, and wait for complete cessation of the cough before per- 
mitting the child to resume the ordinary habits of health. 

If we notice an infra-mammary depression on each side of the chest, 
with some prominence of the lower part of the sternum, we infer that the 
patient has been subject to long-continued or frequently repeated attacks 
of pulmonary catarrh. In these attacks the air-tubes are narrowed by the 
presence of catarrh, so that air penetrates insufficiently into the lungs, and 
expansion, especially of the inferior lobes, is incomplete. As a consequence 
the lower ribs, corresponding to the imperfectly inflated tissue, are re- 
tracted at each descent of the diaphragm. As the lower ribs fall in, the 
lower end of the breast-bone is forced forwards, so that a horizontal sec- 
tion of the chest at this point, instead of elliptical, would be triangular. 
After a succession of these catarrhs a certain amount of permanent collapse 
is induced in the lower lobes, and the deformity becomes a permanent 
one. The prominence of the sternum from this cause constitutes one of the 
varieties of "pigeon-breast." The rickety chest is also pigeon-breasted, as 
is explained elsewhere (see page 139). 

The central cup-shaped depression of the lower end of the sternum and 
corresponding cartilages, sometimes met with, has been referred to in a 
previous chapter (see page 12). 

The movements of the chest in inspiration must be carefully noted. 
Sometimes we find a general exaggeration of movement combined with im- 
perfect expansion of the chest-wall. This abnormality indicates a pressing 
want of air from some impediment to the efficient expansion of the lungs. 
"When bilateral, it is seen in cases of catarrhal pneumonia, in advanced 
phthisis, and in double pleurisy and hydrothorax. When unilateral, it 
may be produced by one-sided pleurisy, pneumothorax (a very rare condi- 
tion in the child), extensive fibroid induration, or condensation of lung 
from a former pleurisy with firm pleural adhesions. 

In early life the thoracic walls yield readily to the pressure of the ex- 
ternal air, and this pliancy is especially noticeable in infants and rickety 
children. Consequently in them dyspnoea is often indicated by more or 
less retraction of the chest-wall in inspiration. This retraction is mostly 
in the infra-mammary region, and in pronounced cases may produce a 
deep horizontal furrow across the base of the chest at the level of the en- 
siform cartilage. If the retraction is limited to this part, it indicates in 
most cases a catarrh of the inferior lobes of the lungs, which are insuffi- 
ciently filled with air ; but if the ribs are very soft t from rickets, the de- 
pression may be noticed in ordinary respiration although the lungs are 
sound. Sometimes the soft parts of the chest also sink in. The intercos- 
tal spaces are hollowed ; the suprasternal notch and supraclavicular spaces 



EXAMINATION OF THE CHEST — PALPATION. 401 

are excavated ; and if the dyspnoea reach an extreme degree, the lower 
half of the sternum with its attached cartilages is depressed into a deep pit 
at each inspiratory movement. When the retraction is thus pronounced, 
there is usually an impediment at the upper part of the trachea. Retrac- 
tion to this degree is seen in membranous and stridulous laryngitis, in 
narrowing of the glottis from any cause, and in cases of lodgement of a 
foreign substance in the upper part of the windpipe. Still, even in some 
cases of pleurisy with effusion, marked retraction is seen on both sides of 
the chest although the impediment to full inspiration only affects one 
lung. 

Enlargement of one side of the chest can sometimes be detected by the 
eye ; but it is more accurately estimated by the cyrtometer. ' A tracing 
made from this instrument upon paper shows immediately if one side of 
the chest be larger than the other. A characteristic sign of pleuritic effu- 
sion is dilatation and squareness of outline of the affected side. 

Unilateral shrinking, from fibroid induration, or old pleurisy with firm 
adhesions, may be also readily estimated by the same means. 

Deficiency of movement of the chest is sometimes better appreciated 
by the hand than by the eye. The hand also detects vibration of the chest- 
wall, if this be present. In children, however, there is seldom a normal 
fremitus when the child speaks or cries ; for in the high-pitched notes 
which alone escape from the childish larynx the vibrations succeed one 
another too rapidly to be readily perceptible by the hand. Consequently, 
unilateral absence of this sign, which in the adult is an important means 
of distinguishing between consolidation of the lung and liquid effusion in 
the pleura, fails us in the case of young patients. Even when detected, 
vocal fremitus furnishes no certain indication. If present on the sound 
side, it may be felt strongly over a liquid effusion, for the vibration is 
readily conducted by the thoracic wall from one side of the chest to the 
other. I have known it to be felt strongly on the affected side in a case 
of recent absorption of pleuritic fluid, although almost absent on the sound 
half of the chest ; and again, in a case of apparently exactly similar kind it 
has been completely absent over the seat of disease, although present else- 
where. 

A rhonchal or friction fremitus is much more common than a vocal 
vibration in the young subject, but the sign is of little value. Fluctuation 
can sometimes be discovered in the interspaces in cases of pleuritic effusion 
and is a valuable sign of the presence of fluid. To detect it, a finger of 
each hand should be placed at the two extremities of the same interspace. 
The impulse of a gentle tap is then often conducted distinctly through the 
fluid from one finger to the other. 

The exact site of the apex-beat of the heart should be always ascer- 
tained, as this may be greatly influenced by disease in the chest cavity. In 
young children and infants the normal position of the heart's apex is 
nearer to the left nipple than is the case in the adult. This is partly 
due to the position of the nipple, which is placed relatively lower than it is 
in later life. In many children, instead of lying over the fourth rib it is in 
the fourth interspace or on the upper border of the fifth rib. But in addi- 
tion to the lower position of the nipple, the heart itself is relatively smaller 
or seems to lie higher in children, especially during the period of infancy. 

1 A perfectly efficient cyrtometer may be made by taking two pieces of soft metal, 
without resilience, such as composition gas-tubing, drawn out to one-eighth of an inch, 
and uniting them by a piece of caoutchouc tubing. 

26 



402 DISEASE IN CHILDREN. 

Often the apex will be found to beat in the fourth interspace, exactly on 
the site of the nipple. 

Diseases of the heart-walls of course influence considerably the position 
of the apex-beat ; but when the organ is healthy, the position of its apex 
may be altered by morbid conditions in neighbouring parts. Effusion into 
the chest cavity causes displacement of the heart's apex. According to the 
side affected the heart may be pushed considerably to the right or to the 
left. In cases of left pleurisy with copious effusion it is not uncommon to 
find the apex-beat of the heart in the epigastrium, and sometimes the im- 
pulse can be felt to the right of the sternum. Cardiac displacement does 
not, however, always result from effusion into the pleura; and therefore its 
absence must not be taken to indicate that the physical signs are capable 
of another interpretation. If adhesions have formed between the pericar- 
dium and the left pleura, the heart is held in place and cannot be pushed 
aside by the effusion. The position of the heart may be also altered by 
contraction of the lung on one side, but in this case the heart is drawn 
towards the affected part. In fibroid induration of the lung, disease on the 
right side moves the heart to the right ; disease on the left side draws the 
organ upwards and to the left. 1 

Besides the position of the heart the exact level of the liver and spleen 
should be noted, as the position of these organs may help us to a conclu- 
sion in a doubtful case. These viscera are often sensibly displaced by the 
pressure of a liquid effusion in the chest, while displacement of the liver 
by the bulging of a croupous pneumonia is so rare as to be a clinical curi- 
osity. If the lung be contracted, the liver or spleen is drawn upwards 
into the chest. 

Percussion of the chest in the infant and young child should be con- 
ducted with deliberation. If care be taken that the hands are perfectly 
warm, and that undue violence is avoided, the process seldom arouses any 
special opposition. It is sometimes recommended to reverse the ordinary 
arrangement and practise auscultation before employing percussion, but 
this inversion of the customary rule is at least unnecessary. 

In the young subject, except perhaps in the new-born infant, the re- 
sonance of the chest is greater than it is in after-life ; and the percussion 
note obtained over an area of consolidation is often so modified by reson- 
ance from healthy tissue around that dulness is only imperfectly marked 
and may escape the notice of an unpractised ear. Percussion should be 
mediate ; and it is advisable always to use two fingers in striking the fin- 
ger placed upon the chest- wall. By this means, without employing undue 
force, a larger body of sound is elicited than if the chest is struck with one 
finger only, and dulness, if present, can be more readily appreciated. As 
we proceed we must be careful to make constant comparison between dif- 
ferent parts of the chest — between opposite sides, between the base and the 
apex, etc. To make the comparison an accurate one the same period of 
the respiratory movement should be chosen for striking upon the finger ; 
for if one part of the chest be percussed at the end of an inspiration, and 
another at the end of an expiration, the difference even in a healthy chest 
may be considerable. When the consolidation consists in scattered no- 
dules, as in the beginning of catarrhal pneumonia or in lobular collapse, 
dulness, which escapes the ear when percussion is made in the ordinary 
manner may often be detected by using "broad percussion," i.e., by strik- 



1 Displacement in the same direction (upwards and to the left) may be a consequence 
of enlargement of abdominal organs or distention cf the peritoneal cavity by fluid. 



EXAMINATION OF THE CHEST — PEECUSSION. 403 

ing with three fingers upon three fingers placed upon the chest-wall as plex- 
imeters. By this means the sound is collected from a larger area of lung- 
tissue than if one finger only were employed. 

But besides the character of the sound elicited in percussion, it is im- 
portant to attend to the degree of resistance of the chest-wall. The resist- 
ance to the percussing finger varies greatly in different cases and is a sign 
of no little importance. In the consolidation of pneumonia and in that 
of pulmonary atelectasis, when the collapse occupies only a superficial layer 
of tissue, resistance is slight. In more extensive collapse, as when the con- 
densed tissue embraces an entire lobe, and in fibroid induration of the 
lung, the resistance is greater ; but the maximum of resistance is reached 
in cases of cirrhosis of the lung, with superadded catarrhal pneumonia, and 
in pleuritic effusion. The resistance is here extreme, and the sensation 
conveyed to the finger is that of percussing a thick block of wood. It is 
very important to educate the sense of touch so as readily to appreciate 
the several degrees of resistance, as this faculty is a great addition to our 
resources in the matter of diagnosis. 

In percussing the supra-spinous fossae it is very necessary to see that 
the muscles of the shoulders are equally relaxed on both sides. Elevation 
of the shoulder, or a cramped position contracting the muscles of one side, 
will modify the percussion note and make the sound more or less dull, al- 
though the lung is perfectly healthy. If an infant be placed in his nurse's 
arms in the position already described, and an older child be made to sit 
with arms folded, shoulders depressed, and back slightly bowed, the re- 
sults of percussion may be depended upon. Too much stress should not 
be laid upon slight differences between the two sides. A temporary col- 
lapse of the air-cells at the apex is not uncommon from imperfect expan- 
sion of this part of the lung, and therefore slight dulness noticed at one 
visit may on the next have completely disappeared. There is also a spe- 
cial source of error in percussing the posterior bases of the lungs in chil- 
dren which it is important to be aware of. In young subjects the liver is 
relatively large, and rises higher on the right side of the chest than it does 
in older persons. There is therefore normally a certain dulness of percus- 
sion in the right infra-scapular region. This dulness is more extensive in 
some healthy children than it is in others. We may recognise the cause 
of the modified note by remarking that the breath-sounds at this point, 
although weak, are perfectly healthy. 

Special varieties of the percussion note have little or no diagnostic 
value in young subjects. The tubular (or tracheal) note is often obtained 
in various states of the lung-tissue, and is not characteristic of any special 
condition. The "cracked-jar" note is a natural phenomenon in early life 
if the yielding chest be percussed during expiration or when the mouth is 
open. 

In auscultation of the chest, however young the child, the stethoscope 
should always be used. This instrument is even of greater value in the 
young subject than it is in the adult, for the chest being smaller, it is more 
important to limit as narrowly as possible the area under investigation. 
I have rarely known children object to its employment if the instrument 
had been first placed in their hands and spoken of as "a trumpet." 
Indeed, the use of this familiar word usually awakens their interest and 
actually facilitates the examination. 

In the normal state the breath-sounds are coarser and harsher (puerile 
respiration) than they become in older persons, and this harshness in cer- 
tain patients is so pronounced that it is not unfrequently mistaken by an 



404 DISEASE IN CHILDKEN. 

inexperienced observer for a sign of disease. The harsh character of the 
breath-sound is especially marked at the apices, and the expiration at this 
part of the lung is often prolonged without the peculiarity being an abnor- 
mal phenomenon. Conduction of sounds from the pharynx and trachea 
to the apices is especially common, and it is not rare to find the respira- 
tion at the supra-spinous fossse curiously loud and hollow or blowing, 
although the lungs are healthy. This hollow breathing is no doubt con- 
ducted from the throat. It is often a sign of enlargement of the bron- 
chial glands, these bodies forming a medium of communication between 
the windpipe and the wall of the chest. It may be heard, however, in 
cases of enlarged tonsils, and is sometimes present, while the mouth is 
closed, in children in whom no other morbid condition of any hind can be 
discovered. In such cases it is greatly modified in character when the 
mouth is open. The source of this variety of blowing breathing can 
usually be detected by noticing that it is heard equally plainly at both 
apices, is chiefly marked in expiration, and is accompanied by no rhonchal 
sound or any dulness of the percussion note. 

Weakness of the vesicular murmur is much less common as a normal 
condition than loudness of the breath-sound. It is, however, present in 
some children as an individual peculiarity. If general over both sides, it 
is a sign of no importance. If limited to particular spots, it is of greater 
moment, and when noticed at the base of one side should not be disre- 
garded. It may be an early sign of pleurisy or may indicate collapse. 
At the apices it often arises from insufficient expansion of lung-tissue, 
and may be of trifling consequence. In such a case it usually passes off 
quickly, and at the next examination may no longer be detected. 

The readiness with which sounds are conveyed from one part of the 
chest to another is a common source of error. Thus, sounds generated at 
the base of one lung may often be plainly heard at the corresponding part 
of the other and healthy lung. In cases of dilated bronchus from fibroid 
induration it is not uncommon to find cavernous breathing with metallic 
gurgling rhonchus at both posterior bases — on the sound as well as on the 
affected side. So, also, a subcrepitant rale developed in one lung may 
be plainly heard on the opposite side, perhaps over the site of a loculated 
pleurisy or collapsed lobe, and give rise to much perplexity. In these cases 
the origin. of the transmitted sound can usually be detected by noticing 
that the quality and pitch of the conducted breath-sound or rale are exactly 
that heard on the affected half of the chest, only diminished in intensity; 
the sound is identical in character but weaker in force. This is rarely if 
ever the case with sounds generated spontaneously in two different spots. 

Bronchial, blowing and cavernous breath-sounds are produced in chil- 
dren by the same mechanism which gives rise to them in the adult, and 
correspond to much the same conditions. In the child, however, peculiar- 
ities in this respect are sometimes noticed. The morbid quality conferred 
upon the breath-sound is often a step in advance of that heard under 
similar conditions in the adult. Thus, cavernous breathing is more often 
a sign of mere solidification of tissue, and is frequently present when the 
lung is compressed by pleuritic effusion. So, also, the amphoric breath- 
sound with tinkling resonance of the voice or cough is almost always the 
consequence of a large cavity or great dilatation of a bronchus. It is heard 
in cases of phthisis, of cirrhosis of the lung, or of subacute catarrhal 
pneumonia. Pneumothorax, to which cause it is almost solely owing in 
the adult, is a very rare condition in the child, and the morbid sign can 
seldom be .attributed to this cause. 



EXAMINATION OF THE CHEST — AUSCULTATION. 405 

Although the auscultatory sounds are frequently magnified in the 
child, it sometimes happens that the contrary condition is found. A patch 
of consolidation, if covered by a layer of healthy luDg-tissue, may give rise 
to no dulness or alteration of breath-sound, and a bronchophonic reson- 
ance of the voice and cry may be the only sign which betrays its existence. 
In crying infants the intensified vocal resonance is an important test of 
consolidation. If the resonance have an segophonic quality it is character- 
istic of moderate effusion. 

The examination of the chest should always be as complete as possible. 
It is not enough merely to examine the posterior part of the thorax, trust- 
ing that if this be healthy the anterior part is healthy too. A patch of 
croupous pneumonia or a loculated pleurisy may occupy any part of the 
lung or chest cavity. Either may be confined to the apex, may he under 
one arm, or may be found seated anteriorly or laterally as well as behind. 
If, therefore the front of the chest is left unnoticed, we may overlook dis- 
ease which closer examination would have discovered. Even if the child 
cry during the operation, much may still be learned. The cry usually 
ceases each time the breath is taken in, so that inspiration is audible. Its 
quality can therefore be ascertained at this time. Moreover, as the chest 
is expanded deeply after a prolonged crying expiration, the air-cells are 
fully inflated and few adventitious sounds can escape our notice. 



CHAPTER II. 

LARYNGITIS. 

Inflammation of the larynx is a not uncommon affection in childhood. 
The disease may occur as a simple catarrh of the larynx or as a more se- 
vere inflammation resulting from a burn or scald. In these cases it is of 
course a primary lesion. It may also occur secondarily as a consequence 
of a constitutional disease, such as tubercle or syphilis. There is a special 
form of the primary affection which is accompanied by spasm and is pe- 
culiar to early life. This complaint is often confounded with membranous 
croup, and is the " catarrhal croup " of the older writers. It is seldom a 
fatal disease, although it produces very alarming symptoms. In the pres- 
ent chapter three varieties of laryngitis will be described, viz., simple 
laryngitis, stridulous laryngitis, and tubercular laryngitis. The lesions 
which affect the larynx in cases of inherited syphilis are referred to else- 
where (see page 204). 

SIMPLE LARYNGITIS. 

Causation. — On account of the sensitiveness of scrofulous children to 
changes of temperature and their liability to catarrh, laryngitis is more 
common in them than it is in others who are free from this unfortunate dis- 
position. In some the larynx seems to have a special proneness to suffer 
in the cold or changeable seasons of the year. No period of childhood is 
exempt from laryngeal catarrh, for^ although the disorder is more often 
seen in children over six years old, it may be met with as early as the end 
of infancy. In infancy, however, the complaint in the simple form is com- 
paratively rare. At this period laryngitis is commonly the con sequence of 
a syphilitic taint. Amongst the children of the poor severe laryngitis from 
burns and scalds is sometimes met with. This form of the disease is al- 
most confined to children between two and three years old, and is due to 
an attempt to drink water from the spout of a kettle as this stands sim- 
mering by the side of the fire. A violent inflammation results from this 
accident and may quickly end in death. An equally severe laryngitis with 
oedema of the glottis is sometimes met with as a secondary affection follow- 
ing serious acute disease. It may occur as a sequel of small-pox, erysipelas, 
or typhoid fever. (Edema of the glottis without inflammation is also 
sometimes a symptom of acute Bright's disease. 

Chronic laryngitis is less common than the acute variety, but some 
times occurs in weakly children as the result of an acute attack. It may 
follow measles or membranous croup, and is apt to prove obstinate. 

Morbid Anatomy. — The mucous membrane and submucous tissue be- 
come congested and cedematous, and their colour is redder than in health. 
In cases of simple laryngitis the change is probably confined to the epi- 
glottis and ary-epiglottidean folds, leaving the true vocal cords unaltered. 



LARYNGITIS — MORBID ANATOMY — SYMPTOMS. 407 

Some thick mucous is secreted. "Ulceration is very rare in early life, and 
probably never occurs in the primary form of the disease. 

In the severe laryngitis which is the result of a scald the soft palate 
and fauces are white and swollen ; and the epiglottis and parts around are 
thickened and congested. A so-called false membrane often forms upon 
the surface. This to the eye appears to be identical with the false mem- 
brane of diphtheria, but is said to differ from it in its microscopical char- 
acters. It is probably, as Dr. Wallace long ago suggested, the natural 
epithelial layer altered in structure. 

Symptoms. — In the mild form the child is hoarse and soon loses his 
voice more or less completely. His cough is hoarse and infrequent ; 
sometimes it occurs in paroxysms. There is little or no fever, and the 
breathing is not interfered with. If the hoarseness do not proceed to ac- 
tual aphonia, it is often more marked in the evening. The cough, too, is 
generally worse at night when the child goes to bed. The hoarseness of 
the voice inay be only noticed when the child is crying. If the patient be 
kept in a suitable temperature, the symptoms of catarrh subside after a 
few days, and seldom last longer than a week. If the indisposition is 
lightly treated, and measures are not taken to protect the child from fur- 
ther exposure, the complaint may become more serious and may be com- 
plicated with spasm (stridulous laryngitis). 

The more severe variety is well illustrated by cases of scald or burn of 
the larynx, although, as has been said, the affection is sometimes due to 
other causes. 

Immediately after the scald the child complains of pain in the throat, 
and this part on inspection is seen to look white and shrivelled ; but there 
is at first no difficulty of breathing and the larynx seems to have escaped. 
The patient screams violently and will not attempt to swallow ; but after a 
time the immediate effects of the accident appear to pass off, and when put 
to bed the child falls quietly asleep. After a few hours, however, usually 
from three to six, his breathing is noticed to be noisy and whistling. 
Laryngitis has now begun. The respirations become laboured and rapid ; 
the face is pale and tinted with lividity about the eyelids and mouth ; the 
pulse is small and feeble ; the skin is cool ; the extremities are cold ; and 
the child is drowsy, although he can be roused with difficulty. If at this 
stage the finger be passed into the back of the fauces, the epiglottis will 
be felt hard and swollen to the shape of a gooseberry or small marble. 
There is recession of the soft parts of the chest in inspiration, and an 
examination detects sonorous and sibilant rales all over the lungs. There 
is no dulness on percussion. 

After a few hoars all the symptoms become aggravated. The breathing 
is more and more laboured and "croupy," the larynx rises and falls rapidly, 
and at each inspiration the soft parts of the chest — the intercostal spaces, 
supra-clavicular fossse, and the epigastrium — sink deeply in. The child 
lies with his head retracted, his face swollen and livid, his eyes injected, 
his nares acting, and his mouth open, making convulsive gasps for breath. 
His extremities are cold, and his pulse is often too frequent and feeble to 
be counted. Although only half conscious the child is much agitated, 
tossing his arms about and showing signs of the greatest distress. Per- 
cussion of the back usually detects some want of resonance, and much 
large bubbling is heard in the air-tubes. Sometimes there is local dulness 
from collapse of lung. In this state the child may sink and die slowly, or 
expire more suddenly in a convulsive fit. 

The above is an aggravated case, but unfortunately far from an uncom- 



408 DISEASE IN CHILDREN. 

mon one. Death may occur as early as twenty-four hours after the acci- 
dent. The end is not, however, always reached so rapidly. The child 
may linger for two, three, or four days before he finally sinks ; or life may 
be prolonged to the end of the week. The duration depends in great 
measure upon the degree of interference with respiration and the patient's 
capacity for taking nourishment. If the oedema of the glottis be less com- 
plete, the breathing after being laboured and stridulous for twenty-four or 
forty-eight hours, with signs of deficient aeration of the blood, may become 
easier, and then gradually return to a normal state. The voice is very 
hoarse and the cough " croupy." In these cases the dyspnoea varies in 
degree from time to time, being subject to occasional increase when the 
child is distressed or made to swallow. After the cessation of the more 
urgent symptoms the voice may remain hoarse and the cough be occasion- 
ally " croupy " for some days. 

A little boy, aged four months, was brought to the East London Chil- 
dren's Hospital at one p.m. On the previous night the bed on which he 
was lying had caught fire, and the child, who had been placed on a water- 
j:>roof cloth, was surrounded with flame and smoke. Hapj)ily he was 
quickly rescued, although not before the palliasse had been nearly destroyed. 
When taken out his body was blackened with the smoke. Soon afterwards 
his breathing became difficult, and at times the mother thought he would 
be suffocated. 

On admission the skin of the arms was seen to be tinted brown from the 
action of the heated air, but there was no external sign of burn. The 
infant's breathing was laboured, and his cry hoarse and weak. At each 
inspiration the soft parts of the chest receded deeply. The face was dusky, 
the nares acted strongly, and the external jugulars and superficial veins 
generally were unusually visible. The fauces looked red and swollen. 
Temperature, 98° ; pulse, 160 ; respirations, 72. In the evening the tem- 
perature rose to 103° ; pulse, 140 ; respirations, 80. The child slept fairly 
well in the night, and in the morning expectorated a piece of membrane 
one inch in length and a quarter of an inch broad. It had the ordinary 
naked-eye appearance of false membrane. The next day the breathing was 
easier and the lividity of the face less. Two days afterwards signs of 
pneumonia were discovered at the left back ; but this disease ran a favour- 
able course, and in about ten days from the time of the accident the child 
was convalescent. He never had any difficulty in swallowing. He was 
treated with hot linseed-meal poultices and a saline mixture containing 
small doses of antimonial wine. 

In cases such as these, if tracheotomy has to be performed on account 
of the intensity of the dyspnoea, the patient often dies from a secondary 
inflammation of the lung. The ordinary non-traumatic laryngitis in the 
child, if at all severe, is also usually associated with bronchitis, pneumonia, 
or pleurisy. 

The chronic form of laryngitis is sometimes seen in connection with 
follicular pharyngitis. It is indicated by an altered quality of the voice, 
which becomes thick and veiled, and is sometimes quite hoarse in the even- 
ing. There is also a hard cough, which may be paroxysmal, and is often 
accompanied by pain shooting up into the sides of the head or the ears. 
I have occasionally met with a simple chronic laryngitis unconnected with 
any abnormal state of the fauces, and apparently not the consequence of a 
constitutional cachexia. One such case, occurring in a child aged one year 
and eleven months, will be afterwards referred to. 

Diagnosis. — The simple form of the disease, where there is much 



LAEYNGITIS — DIAGNOSIS. 409 

hoarseness of the voice and cry, a thick cough, and some redness of the 
fauces, without fever, or with only moderate pyrexia, cannot be mistaken. 
If the symptoms become more urgent, and there is laboured breathing, 
pneumonia and bronchitis may be excluded by the absence of the charac- 
teristic physical signs about the lungs, and the normal or only slightly 
elevated temperature. Still, it must be remembered that these cases, 
whether due or not to a traumatic cause, are often complicated by acute 
chest disease. 

In the case of scald of the larynx, the history will usually be sufficient 
to decide the nature of the illness. It must not be forgotten that in this 
variety of laryngitis the symptoms seldom come on directly after the acci- 
dent, but that there is almost invariably an interval of some hoiu*s before 
the signs of dyspnoea begin to be noticed. In every such case, then, we 
must be on our guard, and must not conclude that all danger has passed 
because the child appears at first to have escaped serious injury. 

In epidemics of diphtheria a slight scald of the larynx may predispose 
a child to fall a victim to the zymotic disease. Mr. Parker has published 
the case of a little girl, aged three years, in whom " croupy " symptoms 
came on three days after an apparently trifling scald of the throat, and in 
spite of tracheotomy the patient died on the sixth day of the illness. On 
examination of the air-passages, the epiglottis and ary-epiglottidean folds 
were covered with membrane ; the tracheal mucous membrane was in- 
tensely injected and coarsely granular in appearance, and this condition 
was seen to extend as far as the tertiary bronchi. Pieces of thinnish, red, 
well-formed membrane were also found on the pharynx and in some of the 
tubes. In this case the illness came on at too late a period after the acci- 
dent to be fairly attributable to the scald ; the symptoms were those of 
laryngeal diphtheria, and the anatomical characters were indicative of a 
sj^ecific and not of a simple inflammation of the larynx and trachea, 

In all cases of chronic hoarseness it is as important in the child as it is 
in the adult to use the laryDgoscope wherever practicable. Children, un- 
fortunately, are usually troublesome subjects for this method of investi- 
gation ; but if the child is old enough to understand the object of the ex- 
amination, we can often, by perseverance and by making him suck lumps 
of ice before the instrument is applied, succeed in getting a view of the 
vocal cords. By this means we can sometimes exclude the presence of 
chronic inflammation and obtain a valuable hint for treatment. It must 
be remembered that hoarseness may be the consequence of the imperfect 
approximation of the vocal cords. Dr. Vivian Poore has referred to the 
case of a little boy who had been long under treatment for laryngitis. In 
this case the hoarseness was found by the laryngoscope to be due to exces- 
sive anaemia of the larynx, with failure in the power of the adductors ; and 
fresh air, good diet, and iron soon restored the lad to health. 

Chronic laryngitis must not be confounded with the alteration of voice 
which occurs as a consequence of enlarged and caseous bronchial glands. 
In that disease hoarseness is a late symptom, and does not appear until 
general pressure signs have been developed in the chest (see page 182). 

Sometimes hysterical aphonia is found in girls. It is distinguished 
from chronic laryngitis by the history. It begins quite suddenly and is at 
once complete. Equally suddenly it subsides. 

A girl, between eleven and twelve years old, was under the care of my 
colleague, Dr. Donkin, in the East London Children's Hospital. The pa- 
tient was one of fifteen children, and there was no neurotic tendency in the 
family. One child had died of croup, and the girl herself had had a 



410 DISEASE IN CHILDREN. 

" croupy " cougli up to the age of seven years. She was of healthy appear- 
ance and seemed very intelligent. Twelve weeks before her admission she 
had been called in the morning and had answered in her usual voice ; 
but when she was dressed it was found that she had complete aphonia. 
Her breathing was natural, and she was not subject to attacks of dyspnoea. 
She had no cough or soreness of the throat, but there seemed to be some 
tenderness at the angle of the jaw. Her voice was quite whispering, but 
she could laugh louder than she could talk. She did not appear to be 
troubled by her infirmity, but was anxious to get well on account of her 
education. 

A galvanic current was applied to the larynx. The girl cried loudly 
during the operation. After a second application of the same kind the 
voice suddenly returned ; and she never relapsed. 

Prognosis. — In uncomplicated cases of simple laryngitis, unless the in- 
flammation be due to a traumatic cause, the child almost invariably re- 
covers. In the traumatic variety the prognosis is very serious. In cases 
which are complicated by some acute lung affection the prognosis depends 
upon the pulmonary rather than upon the laryngeal complaint. 

Treatment. — In ordinary simple laryngitis the child should be kept in 
an equable temperature ; his throat should be enveloped in cotton wool or 
a cold-water compress ; and inhalation should be prescribed of steam im- 
pregnated with tincture of benzoin (a teaspoonful to the pint of boiling 
water). The bowels should be relieved by a mercurial purge ; and if there 
be much oppression of breathing, an emetic should be ordered of ipecacu- 
anha wine. Aftei wards, a saline diaphoretic can be given containing five 
or ten drops of antimonial wine to the dose. A mustard foot-bath is also 
useful. If the cough is troublesome and disturbs the rest, small doses of 
paregoric may be added to the mixture. 

In severe cases, where the dyspnoea is distressing, a blister may be ap- 
plied to the neck below the chin, or towards the top of the sternum. The 
child should be placed in a tent-bedstead, as in diphtheria, and the air 
around the patient should be kept moist by the steam boiler, as recom- 
mended for that disease. The general treatment will depend upon the 
lung affection, which in these cases usually complicates the laryngitis. 

In the violent and distressing cases which result from a scald of the 
glottis energetic treatment is required, as from the moment when the 
dyspnoea becomes urgent the life of the child is in the greatest danger. 
Dr. Bevan, of Dublin, after considerable experience of this form of disease, 
powerfully advocates a return to the old treatment by repeated doses of 
calomel. He states that if this plan be adopted, immediate relief to the 
symptoms is noticed directly green stools begin to be passed, showing 
that the system is under the influence of the drug. Dr. Bevan gives a 
grain of the salt every half hour, and recommends that this medication be 
begun directly the child is seen after the accident, without waiting for 
laryngeal symptoms to declare themselves. He greatly prefers this method 
of treatment to any mechanical measures for admitting air into the lungs, 
as these, he says, are almost invariably followed by death from pneumonia. 
With our improved methods of after-treatment the operation of trache- 
otomy is, however, less often followed by fatal consequences than was for- 
merly the case ; and if the dyspnoea is urgent and threatens life, I should 
not hesitate to advocate the procedure, putting the child afterwards in a 
tent-bedstead in a warmed and moistened atmosphere. 

The calomel treatment certainly seems to offer good results. In each 
of Dr. Bevan's cases the patient took between fifty and sixty grains of 



STRIDULOUS LARYNGITIS — MORBID ANATOMY. 411 

calomel ; and of four children treated in this manner, although the symp- 
toms were excessively severe, all recovered without any sign of having been 
injuriously affected by the remedy. In addition to giving calomel by the 
mouth, mercurial inunctions were used in the worst cases to the skin ; a 
few leeches were applied to the upper part of the chest ; and the bowels 
were relieved by a copious enema. In each case, too, the treatment was be- 
gun by an emetic to clear out the stomach. Dr. Bevan states that green 
stools may be expected in from eight to twenty-six hours after the first 
dose of the calomel. 

It is important to support the strength. If there is total inability to 
swallow, the patient mast be fed with white-wine whey by the stomach- 
tube passed through the nose. 

In cases of chronic laryngitis the throat should be brushed every two 
or three days with a strong solution of perchloride of iron. A little boy, 
aged one year and eleven months, was under my care for chronic hoarse- 
ness of three months' standing. The child, although anaemic, had a healthy 
appearance, and there was no history of syphilis or trace of the disease 
about the body. He was quickly cured by the application to the larynx 
every third morning of a solution of perchloride of iron in glycerine (two 
drachms of the strong solution to the ounce). The application caused no 
spasm or other uncomfortable symptom. 

Iron and cod-liver oil are useful in these cases ; and the throat may be 
painted externally with tincture of iodine. 

STRIDULOUS LARYNGITIS. 

Stridulous laryngitis (false croup, catarrhal croup, spasmodic laryngitis) 
is a common affection in early life. For a long time it was confounded 
with diphtheritic laryngitis, and no doubt a sharp attack of laryngeal ca- 
tarrh with spasm produces sufficiently serious symptoms. The disease, 
however, is rarely fatal. 

Causation. — Stridulous laryngitis is especially a disease of childhood 
after the period of infancy has passed, for it is comparatively rare under 
the age of two years. Between the second and seventh year the disorder 
is common ; but after the latter date it again becomes exceptional. I have 
met with it, however, as late as the fourteenth year. When it occurs in 
the course of the second year the patient will be usually found on exam- 
ination to be the subject of rickets. The complaint appears to be predis- 
posed to by an hereditary spasmodic tendency ; but the patients are not 
necessarily in any way feeble or under-nourished. As a rule, perhaps they 
are sturdy looking and strong. Boys are attacked twice as often as girls ; 
and the affection is frequently seen more than once in the same individual ; 
indeed, it may be said to have a tendency to recur. 

The exciting causes of the complaint are those common to laryngeal 
catarrh. The affection is sometimes an early symptom of measles and 
whooping-cough. It may occur as a complication in the course of the 
latter, and occasionally returns under the influence of a slight chill after 
the attack of pertussis is at an end. 

Morbid Anatomy. — In the rare cases where death has resulted from 
this complaint the glottis and vocal cords have been found little altered, 
or more or less uniformly reddened. Sometimes they have been slightly 
swollen. An excess of mucus has been usually present. It is stated that 
small linear ulcers have been sometimes noticed on close inspection of the 
vocal cords. 



412 DISEASE IN CHILDREN. 

Symptoms. — Stridulous laryngitis consists of a catarrh of the larynx 
with superadded spasm — the spasmodic element being probably the con- 
sequence of special nervous excitability in the individual patient. In some 
children (and these are usually rickety infants) a very trifling degree of 
catarrh may induce spasm. These cases are very mild as a rule, and quickly 
subside. In older children the catarrh is more serious. The complaint 
then lasts longer and is accompanied by more violent symptoms. 

In the mildest form of the complaint the pulmonary catarrh is often 
very trifling. The child may be put to bed apparently well, or with merely 
a slight cold. About eleven or twelve o'clock he starts up suddenly from 
his sleep with a hoarse, barking, sonorous cough, and a loud, whistling, stri- 
dor in his breathing. It will be noticed, however, that the stridulous 
character is confined to the inspiration, and that the expiration is short and 
comparatively noiseless. The movements of the chest are laboured and 
violent, the soft parts sink in at each inspiration, the nares act, and the 
eyes are staring and frightened-looking. If the impediment to breathing 
is great, the face becomes livid, the eyes are injected, and the child is ex- 
cessively restless and agitated. His voice, however, remains hoarse and 
loud. It is rarely weak, and only becomes suppressed and whispering in 
cases of exceptional severity. 

The seizure lasts from a few minutes to half an hour, or even longer, 
for sometimes, after appearing to relax, the spasm becomes again distress- 
ing. In the end it subsides completely and the child falls asleep, but he 
may again be roused up by a milder seizure a few hours afterwards. On 
the following morning he may wake up apparently well, or with some 
slight thickness of the voice and a loud clang in his cough, but these symp- 
toms pass off after a day or two. In many cases the attack returns on the 
following night, and may be repeated yet a third time, but the symptoms 
are seldom so severe as on the first occasion. During the attack the tem- 
perature may rise to 102° or 103°, or higher, but in the morning is usually 
normal. 

In more severe cases of stridulous laryngitis the complaint does not 
pass off so quickly. The catarrh is often not limited to the larynx, but 
also occupies the bronchi. The attacks then occur not only at night but 
also in the daytime, and in the intervals the breathing is more or less op- 
pressed and " croupy," and the voice and cough hoarse. The dyspnoea in 
these cases may be a very serious symptom, the child having the greatest 
difficulty in obtaining even a minimum supply of air. Indeed, in the worst 
cases during the access the face is livid, the hands and nails grow purple, 
the eyes become fixed, convulsive twitchings are noticed in the limbs, and 
an examination of the chest may detect signs of collapse at the bases of the 
lungs. In rare instances the patient dies suffocated unless relieved. The 
complaint is accompanied by moderate fever which persists between the 
attacks, and the complexion remains pale, with some lividity about the lips, 
until the free passage of air is again completely restored. An examination 
of the urine seldom detects albumen, but in the worst attacks, probably 
from renal congestion, albuminuria may be present. 

A healthy-looking boy, aged four years and two months, was taken ill 
on March 1st with sneezing, coughing, and signs of tightness of the chest. 
The same night he was roused by a severe attack of dyspnoea, his breath- 
ing was oppressed and stridulous, and his cough loud and clanging. All 
the next day his voice was weak and hoarse, and his cough barking and 
hard. 

When the child was seen on March 4th, his cough was hoarse and 



STEIDULOUS LAKYNGITIS — SYMPTOMS — DIAGNOSIS. 413 

loud. The breathing was laboured, 46 ; the pulse, 140 ; the temperature, 
101.4°. The skin was moist. The respiratory movements were very labo- 
rious, the shoulders rising and falling, and the soft parts of the chest and 
the epigastrium sinking in deeply. The chest was resonant, and the breath- 
sounds were loud and snoring. One-sixth of a grain of tartrate of anti- 
mony was given every three hours 'in a saline mixture. 

On the night of the 5th the child had another severe attack of dysp- 
noea. He was accordingly put into a tent-bedstead and the air was kept 
moistened by the steam-kettle. The next day the cough was loose, and the 
voice, although hoarse, was much stronger. The dyspnoea did not return, 
and the child was discharged convalescent on March 11th. The tempera- 
ture remained over 100°, morning and evening, until March 9th. 

In an ordinary case of moderate severity the cough loses its hard, bark- 
ing character after a few days and becomes loose, the hoarseness of voice 
diminishes, and the child is soon convalescent. If, however, there be 
general pulmonary catarrh, any neglect may easily aggravate the case into 
one of broncho-pneumonia, or in a weakly subject collapse of the lung may 
occur. In either case the child may die. Fatal cases of laryngitis stridulosa 
are in the large majority of cases so complicated, for few children die from 
the dyspnoea alone. 

In rare cases stridulous laryngitis, like laryngismus stridulus, may be ac- 
companied by carpo-pedal contractions. A little girl, between four and five 
years old, was brought to me for contraction of the fingers, which had much 
alarmed her parents and made them fear that the child was "going to be 
paralysed." The patient was much emaciated from long-continued intes- 
tinal catarrh, and had a pained expression of face. For a month she had 
had a cough, and at night w T as often roused by attacks of stridulous laryn- 
gitis, in which respiration became noisy, and she seemed to have much dif- 
ficulty in getting her breath. On examining her hands the fingers were 
found to be unusually straight-looking, the hands being bent only at the 
knuckles. The child could, however, squeeze well with both hands. It 
was stated that the fingers would often become quite stiff, with the thumbs 
turned rigidly into the palms of the hands. The girl was not rickety ; 
her lungs were healthy ; and there was no enlargement of the abdominal 
organs or mesenteric glands. An iron mixture was prescribed, and the 
child was ordered some claret with her dinner. Under this treatment the 
symptoms soon subsided and the patient regained flesh and strength. 

Diagnosis. — Stridulous laryngitis must not be confounded with true 
membranous croup — a disease to which it often presents a striking resem- 
blance. A distinction between these two affections is of the utmost prac- 
tical importance ; for the operation of tracheotomy, which is especially in- 
dicated in cases of membranous laryngitis, is rarely if ever necessary in the 
stridulous disorder, and if performed imports into the case an element of 
danger which would otherwise be wanting. 

In laryngitis stridulosa the invasion is much more sudden, and the 
dyspnoea at once attains its maximum intensity ; indeed, if the attack be 
repeated it seldom reaches the violence of its first access. The voice in 
false croup, although weakened and hoarse, is rarely suppressed, and the 
child, if persuaded to exert himself, can usually speak fairly loudly. Even 
young children, although silent and unwilling to cry when much hampered 
for breath, if disposed to do so, can often emit a considerable volume of 
sound. The cough, too, is loud and clanging, and rarely assumes the 
muffled, whispering character so distinctive of membranous laryngitis. 
Again, the stridor of the breathing is chiefly marked in inspiration, the 



414 DISEASE IN CHILDREN. 

expiration being much easier and comparatively noiseless. In false croup, 
also, there is no enlargement of the submaxillary glands, such as is apt to 
occur in cases of membranous laryngitis when there is any accompanying 
affection of the pharynx. An examination of the urine rarely discovers the 
presence of albumen. 

In all these features the stridulous catarrh differs from the membranous 
inflammation. In the latter the dyspnoea begins gradually and attains its 
maximum by degrees ; the voice becomes entirely suppressed ; the cough 
is a hoarse muffled sound which is almost pathognomonic ; the stridor is 
as marked in expiration as it is in inspiration ; and albuminuria is some- 
times met with. Lastly, in true membranous croup the diphtheritic 
exudation can often be discovered in the pharynx. Still, absence of exu- 
dation is not to be depended upon as excluding diphtheria, for the mem- 
brane may be limited to the air-passages, and fragments are not always 
coughed up. In a doubtful case, where the symptoms of spasmodic laryn- 
gitis are exceptionally severe, the points to be relied upon for excluding 
diphtheritic croup are : The severe and sudden onset ; the comparative 
absence of stridor in the expiration ; and the quality of the voice, which is 
not completely muffled or suppressed. The age of the patient is also of 
some practical value in diagnosis. In a child under twelve months old, or 
over seven years, the case is very unlikely to be one of stridulous laryngitis. 

Laryngitis stridulosa may be also confounded with laryngismus stridu- 
lus, with retro-pharyngeal abscess, and with oedema of the glottis. The 
distinctive characters of the first-named complaint are elsewhere described 
(see page 271). Retro-pharyngeal abscess is at once recognised by the in- 
ability of the child to breathe when lying down, the increase to his distress 
occasioned by pressure on the larynx, and the presence of a swelling at the 
back of the throat. (Edema of the glottis is usually the consequence of a 
scald or burn, or follows an attack of acute specific disease ; the distress is 
more continuous, without marked remissions in the dyspnoea, and the 
thickened epiglottis can be felt with the finger. 

Prognosis. — As a rule, the child has a good prospect of recovery, even in 
serious cases, if the operation of tracheotomy be not performed. The most 
urgent dyspnoea usually subsides under suitable treatment, and it is very 
rare for the child to die suffocated. When the disease ends fatally, the un- 
favourable issue is usually the consequence of an inflammatory complica- 
tion. Stridulous laryngitis sometimes accompanies the onset of a pneu- 
monia, or from want of proper precautions the tracheal catarrh may be 
allowed to extend into the finer tubes. In such a case the prognosis is not 
favourable, for attacks of suffocation occurring in a child the subject of 
bronchitis or pneumonia are necessarily dangerous. Still, even in these 
cases the child may recover, for often the spasm becomes less marked 
when the inflammatory complication declares itself. 

Treatment. — In the milder attacks of laryngitis stridulosa the child should 
be at once placed in a warm bath (95° Fan.) for fifteen or twenty minutes, 
and should be made to vomit by a dose of ipecacuanha wine. Afterwards 
a small dose of chloral (gr. iij.-iv. to child of eighteen months old) may be 
given, with a few drops of sal volatile, to prevent a relapse in the course of 
the night. In the morning it is well to prescribe a diaphoretic mixture 
(such as vini ipecacuanhse, TFlx. ; liq. ammonia? acetatis, TT[xx. ; glycerini, 
TT[x. ; aq. ad 3 j.), to be taken every three or four hours, and to give directions 
that the child be kept in one room of a suitable temperature. If the 
tongue is loaded, a grain of calomel should be given with two grains of 
jalapine. 



TUBERCULAR LARYNGITIS— CAUSATION. 415 

In the very severe cases a warm bath is also useful. Afterwards the 
child should be placed in a tent-bedstead, in a warmed and moistened 
atmosphere, as recommended for membranous croup. An emetic in all 
these cases produces great relief. A teaspoonful of ipecacuanha wine, or a 
quarter of a grain of sulphate of copper, may be given every ten minutes 
until the desired effect is produced. The vomited matters in all severe 
cases should be searched for shreds or patches of false membrane. As 
long as there is fever the child must be kept in bed. and while the voice 
remains hoarse it is wise to keep the air moistened by means of the steam- 
kettle (see page 103). Tracheotomy is rarely if ever necessary in mere 
spasmodic laryngitis. The most violent attack of suffocation seldom fails 
to be relieved by a warm bath, an emetic, and steam inhalations. Graves' 
plan of applying a sponge wrung out of hot water to the neck, below the 
chin, is also of service. It must not be forgotten to attend to the bowels, 
and a mercurial purge is a great help to the other treatment. 

If the spasms return repeatedly, which, however, is rarely the case if 
the above treatment have been adopted, an antispasmodic may be re- 
quired. Chloral is perhaps the best, and may be given to a child of two 
years of age in doses of three grains three times a day. 

If any inflammatory complication arise, such as bronchitis, pneumonia, 
etc., special measures must be adopted as recommended for these diseases. 
If the case be uncomplicated, diaphoretics should be given when the spasm 
subsides, and the child should be treated for an ordinary pulmonary catarrh, 
taking care to withhold all stimulating expectorants as long as the cough 
continues barking and hard. Sometimes a few drops of paregoric added to 
the saline expectorant mixture seem to aid its effect in reducing the hard- 
ness of the cough. All the time the diet must be regulated as directed 
for pulmonary catarrh. 

In cases where the attacks of laryngitis tend repeatedly to recur, 
endeavours must be made to strengthen the child and diminish his sus- 
ceptibility to changes of temperature. He should be dressed from head to 
foot in woollen underclothing ; should pass much of his time out of doors ; 
and should have a cold douche every morning, given with all the precau- 
tions recommended in a previous chapter (see page 17). Moreover, as 
children with this tendency often have cold feet, care should be taken that 
the extremities are thoroughly warm when the child leaves the house. A 
little alcohol with the dinner is a useful medicine in these cases. 

TUBERCULAR LARYNGITIS. 

In childhood the laryngeal mucous membrane is comparatively rarely 
the seat of the gray granulation ; for it is only in after-life that laryngeal 
phthisis becomes a common manifestation of the tubercular cachexia. 
Still, even at this early age tubercular granules and ulcerations are occa- 
sionally present ; and these usually occur in cases where the force of the 
disease is expended more particularly upon the lungs, the other organs 
being comparatively unaffected. 

Causation. — Ulcers of the larynx are much more common than tuber- 
cular granules without breach of surface. MM. Billiet and Barthez state 
that they have only met with a single case of tubercle of the laryngeal 
mucous membrane unaccompanied by ulceration, and quote a second from 
M. Tonnele, which occurred in a child of fourteen. According to these 
authors, the ulcers are usually of small size, varying from the head of a pin 
to a large lentil. They are circular and cleanly cut, unless they occupy 



416 DISEASE IN CHILDREN. 






the vocal cords. In that case they are more commonly oval, with their 
long diameter in the direction of the cord. Their borders are thin and 
reddish in colour, and their base is usually composed of the submucous 
tissue — rarely of the muscular fibres. The ulcers, for the most part, are 
single, although sometimes more than one is present in the same case. 
The seat may be one or other of the vocal cords, or the posterior angle of 
the glottis, or the base of the epiglottis. The mucous membrane is unal- 
tered or thickened ; sometimes it is reddened. 

The trachea and larger bronchi may be also the seat of ulcers, but more 
usually the tracheal mucous membrance is merely reddened and thickened. 

Symptoms. — The symptoms of the laryngeal complication are often in- 
definite. There may be merely some alteration of the voice, slight pain in 
the region of the larynx, and if there is much swelling, dyspnoea. The 
voice is often thick and husky ; it is never whispering as in the adult. 
The cough is little altered, and has no special quality pointing to this par- 
ticular lesion. There is seldom pain or difficulty of deglutition ; and the 
pain in the larynx, if present at all, is rarely of much moment. The small 
size and limited number of the sores is sufficient, no doubt, to account for 
the absence of special symptoms ; for in the adult, when aphonia is present, 
the ulceration is generally extensive. 

Dyspnoea may be a marked symptom. A little boy, aged two years 
and nine months, whose father had died of consumption, was admitted 
into the hospital, under my care, for difficulty of breathing. For six weeks 
previously his breath had been noticed to be short, and for a fortnight his 
respiration had been accompanied by a stridor. For three weeks he had 
been unable to swallow any solid food, although he could take liquids with- 
out difficulty. 

On admission his dyspnoea was marked. At each inspiration the lower 
half of the breastbone was bent deeply inwards, so as to leave a pit in the 
epigastrium. At the same time the intercostal spaces and supra-clavicular 
hollows were markedly retracted. His nares worked, and all the accessory 
muscles of respiration were in strong action. There was some lividity of 
the face, and the breath-sound was accompanied by a hoarse stridor. His 
voice was hoarse, but not whispering. The cough was little altered, and 
had no metallic or ringing quality. On examination of the chest there was 
some dulness at each supra-spinous fossa, and much coarse bubbling was 
heard all over both lungs. Temperature at 6 p.m., 101.6°; respirations, 40 ; 
pulse, 136. There was no albumen in the urine. 

The boy was in the hospital a week. His dyspnoea all the time con- 
tinued with little change. There were no exacerbations or remissions. 
His temperature varied between 100.6° in the morning, and 102° to 103° at 
night. His bowels acted twice a day, as a rule, although in one day he 
was purged seven times ; and he never complained of pain in the abdomen 
until a few hours before the end. His death occurred quite suddenly. 
The child, after complaining of stomach-ache, which did not appear to be 
severe, suddenly sank into a state of collapse, in which he died. 

On examination of the body many ulcers were found in the ilium, one 
of which had ruptured and caused profuse extravasation into the peritoneal 
cavity. The ulcers were circular, and did not follow the course of the 
vessels, as in ordinary tubercular or scrofulous ulceration. The liver was 
fatty, but the abdominal organs seemed to be healthy. No gray granula- 
tions were seen anywhere but in the lungs. These organs, however, were 
stuffed with them ; and there was some consolidation at the apices. The 
mucous membrane of the larynx and epiglottis was excessively swollen and 



TUBERCULAR LARYNGITIS — DIAGNOSIS. 417 

red, so that the glottis formed a mere chink. No ulcerations were discov- 
ered in this part, and my notes make no mention of gray granulations about 
the larynx. The trachea was healthy, and nowhere was there any sign of 
false membrane. 

In this interesting case the larynx was the seat of severe chronic inflam- 
mation, and had the child lived a short time longer it is probable that 
ulcers would have formed in the glottis. As it was, the intestinal compli- 
cation carried him off before any further change could take place. 

Diagnosis. — In the child, on account of the extreme difficulty of using 
the laryngoscope, owing to the resistance of the patient, it is very rare to 
be able to ascertain by actual inspection the existence of ulcers or granules 
on the laryngeal mucous membrane. In children who have reached the age 
of ten or twelve years the instrument may, however, be sometimes used ; 
but great irritability of the fauces usually attends any laryngeal catarrh, 
and the attempt to inspect the throat has often to be abandoned. 

In coming to the conclusion that a child has tubercular ulceration of 
the glottis we must first exclude ulceration from other causes. Syphilis 
must be set aside by inquiry into the family history, and special antece- 
dents of the patient, and by careful examination of the body for signs of the 
inherited disease. We must also make sure that the child has not suffered 
lately from any complaint which tends to give rise to chronic inflammation 
or ulceration of the larynx, such as measles, small-pox, or membranous 
croup. If all these diseases can be excluded, and we find hoarseness of the 
voice and cough, with stridulous breathing, in a child who is evidently suf- 
fering from tuberculosis, we cannot but explain the local symptoms in the 
light of the general disease. A persistent, steady dyspnoea, without exacerba- 
tions or remissions, would add strength to the explanation. If, however, 
suffocative attacks come on, and the child is first seen when suffering from 
more or less paroxysmal dyspnoea, an exact diagnosis may be very difficult. 
The history would, indeed, point to a chronic interference with the action 
of the glottis ; but such interference might be produced by warty growths 
or polypi of the vocal cords, and without a laryngoscopic examination a 
diagnosis is probably impossible. Such a case as the following, for example, 
would give rise to great perplexity. 

A little boy, four years old, but short for his age, and of rickety build, 
who had been treated for syphilis in his infancy, is brought to the hospital 
for difficulty of breathing. It is said that for four months he has been 
noticed to breathe stertorously and to have a hoarse cough. The cough is 
worse at night, and is often followed by vomiting. The child's face is 
rather turgid and congested, and the jugular veins are visible. On inspec- 
tion of the chest it is seen that at each inspiration the ribs and lower half 
of the breast-bone are greatly retracted. At the same time the pulse fails 
in force, and there is a stridulous sound from the throat. Examination of 
the chest shows no sign of disease; resonance is normal, and a loud stridor 
conducted from the throat is heard at all parts of the chest-wall. The 
heart's apex is in the normal site. An attempt to make a laryngoscopic 
examination has to be abandoned on account of the child's struggles. 
Temperature at 9 a.m., 101. 8 3 ; pulse, 140 ; respirations, 36. 

After admission into the hospital the temperature for the first eleven 
days is over 100°, both morning and evening. The child is found to suffer 
froni severe fits of dyspnoea, which come on usually at night. In these 
attacks he is excessively agitated, sitting up in bed and throwing himself 
about, his face gets livid and his lips are blue. He makes constant at- 
tempts to cough, as if to remove some obstacle, but the cough is very hoarse 
27 



418 DISEASE IN CHILDBED. 

and smothered. In one of these attacks the distress is so great, and the 
signs of approaching suffocation so pronounced, that tracheotomy is per- 
formed. After the operation the breathing is easier, but signs of pneu- 
monia manifest themselves, and the child dies. After death an examination 
of the larynx discovers several warty growths attached to the true vocal 
cords. One of these growths is long and pedunculated. 

In a case such as the above, if a correct diagnosis can be arrived at in 
the absence of a laryngoscopic examination, it can only be by exclusion; 
but the elevated temperature would be an element of perplexity, and 
would not be in favour of warty growths. A digital examination is of little 
value in such a case, for the growths, being seated on the true, vocal cords, 
are quite out of reach of the finger. 

Prognosis. — The prognosis is always unfavourable, but the gravity of 
the case depends much upon the general disease and little upon the laryn- 
geal complication. It is only in cases where the inflammatory swelling 
has almost occluded the opening of the glottis that any special danger is 
likely to arise from the condition of the larynx. These cases, fortunately, 
appear to be very rare. 

Treatment. — Little can be done in the way of special medication for tu- 
bercular laryngitis. The treatment to be adopted must consist of the 
measures recommended in cases of simple inflammation. The neck should 
be kept warm externally, and inhalations of steam, medicated with the 
compound tincture of benzoin, should be prescribed. If the cough is 
troublesome and disturbs the rest, small doses of laudanum, morphia, or 
paregoric may be administered. Two to three drops of liquor morphia?, 
with the same quantity of spirits of chloroform and ten of glycerine, in a 
teaspoonful of water, form a useful linctus for these cases. The general 
treatment must be that recommended for the constitutional affection. 



CHAPTER III. 

SUPPURATION ABOUT THE LARYNX. 

The formation of an abscess in connection with the larynx is not a com- 
mon complaint at any period of life. But the disease, when present in the 
child, causes so much interference with respiration, and produces symptoms 
which bear so close a resemblance to those of membranous croup, that it 
must not be passed over without a word of notice. 

Three cases of suppuration about the larynx were published some years 
ago by Dr. W. Stephenson, of Aberdeen. Two others have been placed 
upon record by Dr. John S. Parry, of Philadelphia. A few cases are also 
scattered about in the various journals. 

Causation. — A state of feeble health appears to favour the occurrence 
of the disease, for the patient is generally weakly and cachectic-looking. 
In two of Dr. Stephenson's cases the child was just convalescent from an 
acute specific disease (scarlatina and small-pox). In a case narrated by 
MM. Killiet and Barthez, under the name of submucous laryngitis, the boy 
(aged four years and a half) was still in a weakly condition after an attack 
of measles. A preliminary period of ill-health is not, however, indispen- 
sable, for in one of Dr. Parry's cases (a little negro baby of four and a half 
months old) the infant seemed to be in perfect health just before the first 
symptoms appeared. 

Morbid Anatomy. — The abscess is usually situated at some point in the 
immediate neighbourhood of the larynx. In one of Dr. Stephenson's cases 
its seat was at the outer side of the right thyroid cartilage, laying bare the 
upper margin, and extending to the superior cornu. It had opened inter- 
nally. In another a sac containing pus was seated in front of the thyroid 
cartilage, and extended upwards on each side as far as the upper margin 
of the alse of the cartilage, the pouch on the right side being somewhat 
larger than that on the left. In one of Dr. Parry's cases an exactly similar 
condition was met with. The thyroid cartilage itself may be eroded and 
roughened and denuded of perichondrium. 

Symptoms. — The symptoms produced by suppuration around the lar- 
ynx are very similar to those which arise as a consequence of retro-pha- 
ryngeal abscess, for in both cases there is pressure upon the air and food 
passages. There is dyspnoea and laboured breathing ; hoarse, noisy inspi- 
ration, and increase of distress in the recumbent position. Swallowing is 
greatly impeded ; the child, if an infant, refuses the breast ; if older, he 
cries when an attempt is made to force him to take nourishment. An 
effort to swallow is often followed by cough, and an increase in the dysp- 
noea, with return of the fluid through the mouth and nose. 

The most prominent symptom is the dyspnoea. The child's eyes are 
prominent and his face dusky. His breathing is hurried (40-50) and his 
nares act with respiration. If an infant, he lies back, with head retracted 
and the muscles of the nucha rigid. If able to sit up, he sits huddled 



420 DISEASE IN CHILDREN. 

together in Ms cot instead of lying down, and whimpers if disturbed. 
Each inspiration is accompanied by a loud rattling stridor, and at the same 
time the soft parts of the chest are retracted and the epigastrium is 
depressed. The expirations are short and comparatively noiseless. The 
difficulty of breathing varies in degree. It is subject to exacerbations, dur- 
ing which the child is in the greatest agitation, and seems on the point of 
suffocation. In the intervals, although quieter, he is still greatly distressed. 
Anything which irritates or disturbs the patient, such as attempts to give 
food or medicine, encourages the attacks ; and if he try to swallow, the 
dyspnoea comes on at once. The voice is almost suppressed, and the cry 
is hoarse or whispering. Cough is either absent or is merely hoarse with- 
out clangor. In one case it was paroxysmal. 

The physical signs of the chest are normal, with the exception of the 
loud stridor which is transmitted to all parts of the chest-wall and quite 
obscures the normal vesicular murmur. On examination of the throat the 
fauces appear to be perfectly healthy, and the finger pushed to the back of 
the pharynx finds no tumour such as is present in cases of retropharyngeal 
abscess. At first, too, the most careful examination of the neck may 
detect no deviation from the normal state ; but after a few days a little 
swelling may perhaps be discovered on careful inspection. In some cases 
the larynx has been usually prominent or pressed out of the mesial line. 
The swelling in most of the cases appeared at some part of the posterior 
border of the thyroid cartilage, just in front of the sternomastoid muscle, 
and in two cases it spread to the front. In one instance it was noticed to 
become more prominent in expiration, and to recede again in inspiration. 
The swelling is not hard, and rarely fluctuates ; indeed, as Dr. Stephenson 
remarks, "it may feel more like air than fluid." 

If the swelling is punctured and the accumulated pus let out, instant 
relief is obtained. The dyspnoea subsides and rapidly disappears ; the 
child takes food without hesitation or difficulty, and the cough im- 
proves. The voice may, however, remain feeble for some weeks after- 
wards. The duration of the disease is short. In all published cases 
the suppuration ran an acute course, and ended fatally in many instances. 
As in the case of abscess behind the pharynx, death may be the conse- 
quence of exhaustion, or the child may die suffocated in an access of 
dyspnoea. 

Diagnosis. — In reading the above description of the phenomena attend- 
ing upon suppuration about the larynx the resemblance of the disease, in 
its course and symptoms, to retro-pharyngeal abscess cannot fail to be re- 
marked. We find in each instance difficulty of swallowing, paroxysmal 
dyspnoea and stridulous breathing, and a marked increase in the child's 
distress when he lies down. In either case, too, the trachea may be pushed 
out of place and may be more prominent than natural. The chief distin- 
guishing mark is the presence of a tumour in the fauces if the abscess is 
situated behind the pharynx ; while if the suppuration occurs around the 
larynx the fauces are natural. 

The distinction between such a condition and membranous croup is 
described elsewhere (see page 594). It may, however, be here noticed that 
in children who are old enough to sit upright, orthopncea is a very charac- 
teristic symptom of interference with the passage of air through the laiwnx 
and trachea from outside pressure. In membranous croup no such symptom 
is noticed, for in that disease there is no aggravation of the dyspnoea when 
the child is recumbent. On the contrary, he often breathes more easily in 
that position. Again, the progression of the symptoms is more gradual in 



SUPPURATION ABOUT THE LARYNX — TREATMENT. 421 

the case of abscess. The stertor comes on more slowly and increases in 
intensity as the sac increases in size. 

Prognosis. — The prospect of recovery depends upon the general health 
of the child, and upon the appearance of local swelling or fluctuation at 
some point in the front of the neck. If the abscess can be detected and its 
contents evacuated, recovery may take place ; but if the child be a feeble 
cachectic subject, especially if he be much exhausted by sleeplessness and 
want of food, the operation may come too late to save life. In this disease 
the prognosis is distinctly less favourable than it is in retropharyngeal 
abscess. 

Treatment. — If the presence of an abscess about the larynx be suspected, 
the throat should be enveloped in hot poultices, frequently changed, so as 
to hasten the formation of matter and quicken its approach to the surface. 
If any swelling can be detected by the side of the thyroid cartilage, it 
should be punctured with a small trocar without reference to the absence 
of fluctuation. Even if no swelling can be seen, in cases where the symp- 
toms are very urgent and we feel strong suspicions of the formation of pus 
in the neighbourhood of the larynx, it is justifiable to make exploratory 
punctures. Some point on a line with the posterior border of the thyroid 
cartilage should be chosen for the operation. If the exploration be at- 
tended by no satisfactory result, and the symptoms continue urgent, trache- 
otomy should be performed. 

At the same time every effort should be made to support the strength of 
the child. Port wine should be given, or the brandy-and -egg mixture ; 
and pounded meat made fluid with gravy or strong beef-tea, eggs and milk, 
etc., must be administered in suitable quantities. If the child cannot 
swallow, he must be fed, if possible, through a stomach-tube introduced by 
the nose. 



CHAPTER IV. 

CROUPOUS PNEUMONIA. 

Cboupotjs or lobar pneumonia may be seen at any period of childhood, but 
in infancy is comparatively rare. Up to the end of the second year inflam- 
mation of the lung usually assumes the catarrhal form, and even in the 
third year pneumonia is more often catarrhal than croupous. After the 
third year both forms of the disease are about equally common, and with 
each succeeding year inflammation of the lung, if it occurs, is more and 
more likely to be of the croupous variety. 

Causation. — Of late years a tendency has been growing to look upon 
croupous pneumonia as an acute general disease, of which the pulmonary 
consolidation is the anatomical expression, and no longer to regard it as a 
mere local inflammation. Some observers have compared it to acute rheu- 
matism and tonsillitis. Others, who see in the affection the effects of a spe- 
cial poison, have even placed it in the same class with typhoid fever and 
other similar specific distempers. 

That the disease is a general one, with a marked local manifestation, 
seems to be evident, for the general symptoms are not proportioned in 
severity to the extent of lung surface involved ; they may precede by some 
days any evidence of local mischief, and the highest elevation of tempera- 
ture is often reached before the point of most complete consolidation is 
arrived at. Moreover, the character of the symptoms differs in many re- 
spects from the ordinary type of constitutional disturbance set up by a 
local injury : head symptoms are more common, sweating is more frequent, 
and a herpetic eruption is an ordinary phenomenon. Again, the morbid 
exudation, which is the chief local expression of the disease, is of a kind 
peculiar to pneumonia, and cannot be produced by ordinary inflammatory 
agency. Still, although the affection may be a general one, it does not 
follow, as some observers are disposed to believe, that it ought to be classed 
amongst the diseases which result from specific infection. There are no 
doubt some facts which seem to favour this view. Thus, pneumonia has 
been occasionally known to occur in epidemics, and in some outbreaks 
facts have been noted which seem to point to personal communication of 
the disease by contagion. The illness sometimes appears to be preceded 
by a prodromal interval, and to pass through a stage of invasion before 
local symptoms are manifested; it runs a definite, uniform course ; is often 
accompanied by complications which assume different degrees of prom- 
inence in different outbreaks, and its type varies in severity, the rate of 
mortality being higher in some epidemics than it is in others. In ail these 
features the disease seems to incline to the class of acute specific maladies. 
The question whether or not the illness can be set up by impressions of 
cold, is one of great importance, for if it can arise from a simple chill, the 
disease can have no pretensions to be the consequence of a specific poison. 
There is a conflict of testimony upon this point. It is said that pneumo- 



CROUPOUS PNEUMONIA— CAUSATION — MORBID ANATOMY. 423 

nia is most frequent in the tropics, and diminishes in prevalence as the 
distance from this zone increases. It is not especially common in cold 
latitudes ; and Koch in his cases failed to trace any relation between the 
attack and the external temperature. Other observers, however, have no- 
ticed a connection between the illness and meteorological conditions ; and 
there is no doubt that in seasons where the temperature is changeable and 
the weather damp the disease is more common than at times when the 
temperature is uniformly high or uniformly low. Biach states, as a result 
of his observations, that the coincidence of rapid atmospheric depression, a 
low temperature, and sudden changes of temperature tends to produce the 
disease. 

Perhaps in the present state of our knowledge it may be sufficient to 
class pneumonia with tonsillitis, and, indeed, it bears a great resemblance 
to that disease in the conditions under which it appears to originate. In 
addition to cold, bad drainage seems to have a powerful influence in excit- 
ing the malady. Many mysterious cases of pneumonia arising in schools 
have been finally traced to contamination of the air of dormitories by sewer- 
gas, and have ceased after measures' have been taken to rectify the faulty 
condition of the drains. 

Pneumonia sometimes occurs secondarily to other forms of illness. 
Thus it may be a consequence of an altered state of the blood, as in the 
acute febrile diseases, or may be due to imperfect purification of the blood, 
as in Bright's disease. In other cases, again, it may be a purely accidental 
complication. 

Lastly, although pneumonia often attacks children who are to all ap- 
pearance strong and healthy, its occurrence, like that of other acute diseases, 
is favoured by conditions which reduce the strength and lower the resist- 
ing power. Therefore impairment of health must be looked upon as one 
of the predisposing causes of the malady. 

Morbid Anatomy. — The morbid processes which constitute an attack of 
pneumonia are divisible into three well-marked stages. In the first — the 
stage of engorgement — there is congestion of the capillary vessels which 
ramify between the air- vesicles and on the minute bronchia, and swelling 
of the alveolar epithelium. The organ is heavier than natural, and darker 
in tint. It still contains air, and therefore crepitates on pressure although 
less perfectly than natural ; but its substance tears readily, retains the mark 
of the finger, and on section pours out a reddish, frothy fluid from the 
divided surfaces. 

In the second stage — the stage of red hepatisation — the alveolar epithe- 
lium is swollen and granular. An exudation of the constituents of the 
blood coagulates in the air-vesicles. The alveoli and small air-passages 
connected with them are crowded with white and red blood corpuscles, 
which distend these little cavities and cause complete consolidation of the 
lung. The affected part, therefore, is airless and can no longer crepitate. 
It tears with the utmost ease. Its bulk is increased ; it sinks in water ; 
and on section the surface is dryish and somewhat granular, although 
pressure causes a thick, turbid fluid to ooze out. The colour is reddish- 
brown, marbled here and there with gray. Usually the adjacent pleura is 
also inflamed. It is opaque and congested, and adhering to it are patches 
of lymph. 

In the third stage — the stage of gray hepatisation — the colour of the dis- 
eased part of the lung becomes grayish or whitish-yellow. White blood 
corpuscles continue to exude into the air-cells, and there is besides prolif- 
eration of the alveolar epithelium ; so that with the microscope we find 



424 DISEASE IN CHILDEEN. 

epithelial cells, granule cells, and leucocytes. The fibrinous exudation dis- 
integrates, and the cells quickly undergo fatty degeneration. The organ 
is still heavy and airless, and is very soft in consistence, so that a little 
pressure breaks it down. The cat or torn surface is but slightly granular, 
and on pressure gives out a puriform fluid. 

These various stages of the disease may usually be seen to occupy 
different part of the lung at the same time ; for as the disease spreads from 
one part of the organ to another, it is far more advanced in the part first 
attacked. The extent of tissue involved is subject to great variety. The 
affection may be limited to a small patch, or may involve a whole lobe, or 
even the entire lung. It attacks the base by preference, but is far from 
uncommon at the apex, especially in the child. Usually the consolidation 
is confined to one side of the chest ; but double pneumonia is said to be 
more common in children than in adults. 

The process of resolution in the affected part consists in a fatty degen- 
eration and liquefaction of the contents of the alveoli and small air-tubes. 
Thus softened and liquefied the inflammatory products are readily absorbed 
or coughed up ; the air-cells are freed ; and the circulation through the 
capillaries ramifying on the alveolar partitions is restored. Resolution is 
the normal and favourable termination to a croupous pneumonia ; and if 
the illness be primary is the common ending in the child. In exceptional 
cases, usually when the disease is secondary, suppuration may occur w T ith 
the formation of an abscess, or the inflammatory process may pass into 
gangrene. Still, gangrene is rare as a consequence of pneumonia; and 
probably never occurs as a result of the uncomplicated disease. It may, 
however, follow in cases where emboli derived from ante-mortem clotting 
in the right heart are arrested in the pulmonary capillaries. If Bouillard's 
statement that a peculiar tendency to the formation of such clots is a 
common feature of the true pneumonic disease be correct, it is surprising 
that the gangrenous change is not more often met with. Croupous pneu- 
monia is not a cause of phthisis. A simple unabsorbed consolidation, such 
as is common after catarrhal inflammation of the lung, rarely if ever results 
from the croupous form of the disease. 

On account of the apparent analogy between pneumonia and the acute 
specific diseases, pathologists have searched carefully amongst the morbid 
products in the lung for signs of microscopic organisms, such as have been 
shown to exist in cases of erysipelas. Friedliinder, of Berlin, in searching 
amongst the fibrinous effusions in the bronchial tubes, and in examining 
sections of the lung-tissue and inflamed pleura, found in each of eight 
cases submitted to investigation ellipsoidal micrococci which were coloured 
deeply by the aniline dyes. The organisms were found, as a rule, arranged 
in pairs or chains ; but in some parts they swarmed in enormous numbers, 
especially in the interior of the alveoli and the lymphatic vessels. Koch, 
Klebs, and other observers have also described similar organisms. 

Symptoms. — The onset of croupous pneumonia is sudden, and is usually 
marked by signs of great perturbation of the nervous system. The child 
is often convulsed, and the eclamptic seizures may succeed one another, 
with only short intervals of quiet, for hours together. In other cases the 
patient complains of severe headache and pains about the chest. He vomits 
repeatedly ; shivers or cowers over the fire ; and towards the evening may 
become delirious. From the first the temperature is high, the thermometer 
marking 103°-105°, or a still greater elevation. From the first, too, cough 
is noticed, and is a source of much distress from the pain it excites in the 
.chest. The cough is characteristic. It assumes the form of a short, sharp 



CBOUPOUS PNEUMONIA — MORBID ANATOMY— SYMPTOMS. 425 

hack, and in older children may be accompanied by the expectoration of a 
rusty sputum. The cheeks are brightly flushed ; the eyes look heavy, and 
the face is distressed ; the nares act ; the tongue is thickly furred ; epis- 
taxis is a common symptom ; and the weakness is often from the first a 
notable feature in the case. This weakness often amounts to marked mus- 
cular prostration. An infant lies quietly and takes no notice of what goes 
on around him. An older child seems stupid, and often makes no reply to 
questions addressed to him, as to do so requires an amount of exertion to 
which he feels himself unequal. 

As the disease goes on there is little alteration in the symptoms. The 
child lies on his back in his bed. He is very thirsty, but has no inclina- 
tion for food. His face continues flushed, and often a patch of herpes is 
seen on the upper lip. His breathing is hurried and short ; and its rhythm 
is altered, the pause taking place at the end instead of at the beginning 
of inspiration. This is probably due to an effort to suppress the cough. 
The peculiar character of the cough has been already referred to. It 
occurs in short single hacks, one to each short inspiration ; and these often 
continue until the child seems quite exhausted. 

After three or four days the flush disappears from the cheeks, and the 
face is left pale, with a little lividity about the eyelids and mouth. The 
nervous symptoms also subside, and the nocturnal delirium rarely lasts 
longer than three or four nights. Usually the period of completion of the 
exudation is marked by a subsidence of the more severe features of the 
case. The temperature remains elevated, but the child looks less dull 
and self-absorbed ; his expression of distress passes away, and he takes 
some interest in what is going on around him. The period of resolution 
is marked by a sudden fall of the temperature, which sinks below the level 
of health, and the child passes rapidly into a state of convalescence. 

The more special symptoms will now be considered in detail. 

Nervous symptoms are, as a rule, more violent at the beginning of the 
disease. Convulsions cease after a few hours, and although delirium may 
persist for several nights, it rarely continues after consolidation has been 
completed. Severe cerebral symptoms are said to be more common in 
cases where the apex of the lung is the part to be attacked, but they are not 
limited to such cases ; indeed, in children they are often quite as marked 
when any other part of the lung is involved. It is very common to find a 
pneumonia of the apex unaccompanied by any sign of nervous irritation ; 
and according to my experience inflammation of this part of the lung, in 
the large majority of cases, runs in the child an especially short and favour- 
able course. 

When nervous s} r mptoms occur the form they take is subject to con- 
siderable variety. In infants there is usually great drowsiness, preceded, 
perhaps, by convulsions, and often accompanied by twitchings of the facial 
muscles and of the muscles of the limbs. Sometimes the child clutches at 
his mother's dress as if in fear of falling ; and when the drowsiness passes 
off he cries fretfully as if in pain. In an older child severe headache and 
delirium are usually the most prominent of the nervous symptoms. Thus, 
a little girl, aged nine years, came back from school complaining of head- 
ache and pains in the chest and back. For the next two days she vomited 
repeatedly, groaned with the pain in her head, and was delirious at night, 
lying with her head back and her arms up to her forehead. There was no 
squint ; her nose bled once, and she coughed and expectorated phlegm 
streaked with blood. The child was seen at the hospital three days 
afterwards. Her temperature was then (6 p.m.) 103°, and there was con- 



426 DISEASE IN CHILDREN. 

solidation of the lower two-thirds of the left lung on the posterior as- 
pect. 

In many cases where nervous symptoms are prominent there is a sallow 
tint of the face, with tenderness over the liver, and a constipated state of 
the bowels. The symptoms of nervous excitement do not appear to be 
dependent upon undue elevation of temperature, for they do not neces- 
sarily occur in cases where the pyrexia is most marked ; nor do they seem 
to have any connection with the ordinary reflex excitability of the nervous 
system so common in the young child. 

A little girl, aged three years, was noticed to be very restless and irri- 
table for a fortnight. At the end of that time she had a fit while at dinner. 
The child was brought to the hospital and remained convulsed for two 
hours. She was kept in the hospital for about a week, on account of 
twitchings in the muscles and a certain excitability of manner, although 
she had no return of the fits and seemed to be perfectly intelligent. The 
bowels were costive and had been much confined, otherwise no derange- 
ment of organs could be discovered. After her discharge the child 
remained well for a fortnight, and was then brought back to the hospital 
with an attack of lobar pneumonia involving the lower part of the right 
lung. In this attack, although the temperature was high (about 104°, both 
morning and evening) the illness had not been ushered in by convulsions ; 
there was complete absence of nervous excitement ; and the disease ran 
an exceptionally mild course. 

The breathing in pneumonia is hurried from the first. There is no 
actual dyspnoea, for in an ordinary case we find none of the distress which 
is seen when a child is consciously suffering from shortness of breath. He 
lies down in his bed and requires no support by additional pillows. The 
nares dilate widely, but the respiratory movements are merely increased 
in rapidity without being exaggerated in degree. The pulse is also quicker 
than normal, but is proportionately less hurried than the breathing. Con- 
sequently there is a disturbance of the relation naturally existing between 
the pulse and the respiration which is a very important symptom. The 
ratio from being 1 to 3.5 is reduced to 1 to 2.5 or even 1 to 2. Thus, 
a respiratory rate of 75 with a pulse rate of 140 is very commonly met 
with. Although the rapidity of breathing is not accompanied under ordi- 
nary circumstances by a feeling of dyspnoea, the child shows by his man- 
ner that the supply of air to his lungs is a pressing necessity, for he will 
not willingly allow the process to be interrupted. He will bear much dis- 
comfort without complaint, and indeed the passiveness of a young child 
under examination is a characteristic feature of the disease. If he begin 
to cry he usually ceases to do so very quickry. If he suck, he does so 
hurriedly, stopping at short intervals to breathe through his half-open 
mouth, as air cannot be admitted in sufficient quantity through the nose. 

The tongue is thickly furred, and in severe cases may become dry and 
brown. Vomiting often occurs at the beginning. The bowels are usually 
confined, but may be loose, and in exceptional cases there is profuse diar- 
rhoea. The appetite is completely lost, and there is great thirst. 

The urine is diminished in quantity. Its specific gravity is high, and 
it is often thick with lithates. The excretion of urea and uric acid is 
above the average of health ; but there is a great diminution in the amount 
of chlorides ; and at the height of the disease these salts may disappear 
altogether from the urine. Occasionally there is albuminuria ; and bile 
pigment is often noticed. 

The pyrexia is high from the first, and the remission in the morning is 






CROUPOUS PNEUMONIA— SYMPTOMS. 427 

often very slight, seldom exceeding a degree or a degree and a half. The 
temperature rises usually to between 103° and 105°, but may be higher. 
It often reaches its maximum on the third day. When the temperature 
falls it falls suddenly. Thus, in the case of a little girl, aged five years, 
on the evening of the fifth day the thermometer registered 104.2°. It then 
began to fall. At 10 p.m. it was 101.2° ; at 2 a.m. on the following morning- 
it was 100.2° ; and at 6 a.m. 99°. It remained all day at this level, being the 
same at 10 p.m. 

Although in ordinary cases of pneumonia there is no actual dyspnoea, 
in exceptional instances we find serious suffering from want of breath. It 
occasionally happens that when a large area of lung has become rapidly 
consolidated the heart's action is seriously embarrassed by the impediment 
to the pulmonary circulation. The over-distended right ventricle labours 
violently to force the circulation onwards ; but its walls soon become 
weakened and dilated by the pressure to which they are exposed. We 
find the child propped up in his cot struggling for breath with a pale or 
livid face. His nares dilate widely at each inspiration ; the chest-walls are 
forcibly elevated, but expand only imperfectly ; and there is great recession 
of the suprasternal notch, the intercostal spaces, and the epigastrium as 
each breath is drawn. The child can hardly speak, but his expression in- 
dicates terror and distress, and beads of sweat often stand upon his brow. 
On inspecting the chest the right auricle can usually be seen beating in 
the second and third interspaces to the right of the sternum ; the heart's 
action is violent, while the pulse at the wrist is so feeble as to be hardly 
perceptible. There is, indeed, little blood in the systemic circulation, but 
the pulmonary system is engorged. These cases are not so common in the 
child as they are in the adult ; but they are occasionally met with in early 
life, and unless prompt assistance be rendered may quickly prGve fatal. 

A physical examination of the chest may not at first discover any signs 
of the inflammatory lesion in the lung. Often two or three days elapse 
before any characteristic changes are to be discovered by the finger or the 
ear. Usually on the first day or two the percussion-note is normal, and 
with the stethoscope we find merely a sonoro-sibilant rhonchus scattered 
more or less widely over the lung. Even when consolidation occurs, if 
this be situated in the middle of a lobe, we may find bronchial breathing, 
with a puff of fine crepitation at the end of inspiration, but the percussion- 
note may be normal as long as a thin layer of healthy lung-tissue intervene 
between the diseased spot and the surface. 

In an ordinary case the physical signs of the disease are as follows : 

During the stage of engorgement inspection can seldom discover any im- 
pairment of movement on the affected side. In young children this is 
always difficult to detect, for the respiration being chiefly diaphragmatic, 
the chest-walls take a comparatively small part in the respiratory move- 
ment. There may be at first no dulness on percussion, or the note may 
have a slightly higher pitch than that over the sound lung. The breathing 
is very harsh and rather louder than natural, and towards the termination 
of this stage a fine puff of crepitation is caught at the end of inspiration. 
This is usually only to be heard when the child draws a deep breath. In 
ordinary breathing there may be a little coarse bronchitic rhonchus both 
with inspiration and expiration which presents nothing characteristic. 

In the stage of hepatisation a faint vocal vibration may be sometimes 
detected over the affected side when the child speaks or cries. This sign 
is a very capricious one. It may be noticed in very young subjects and be 
absent in a much older child. If present, it is a sign of value, but no 



428 DISEASE IN CHILDREN. 

inference can be drawn if it fail to be perceived. The percussion-note 
over the affected part is now dull; but the dulness is far from being 
complete, as in pleurisy. The sense of resistance, too, although increased, 
is not extreme, as in the case of effusion. It is rather greater than natural, 
and that is all. In babies and young children the increase of resistance 
may be very trifling. Auscultation over the consolidated spot discovers a 
loud tubular breath-sound, and the crepitation, which was before heard at 
the end of inspiration, is now no longer to be perceived, although at the 
borders of the solidified region it may still be detected. If the child can 
be persuaded to speak, the resonance of the voice is high-pitched and 
sniffling, and is conducted with much greater distinctness than natural to 
the ear. This sign is, however, not always present, and in a case of un- 
doubted consolidation the resonance of the voice may be normal. Indeed, 
in exceptional cases — owing possibly to plugging of a tube with mucus- 
vocal resonance, and even blowing breathing itself, may be indistinct and 
distant-sounding, or even altogether suppressed. On the other hand, if the 
consolidated spot is in the middle of a lobe, completely surrounded by 
healthy tissue, and the patient be an infant, a bronchophonic resonance of 
the cry may be the only sign to be detected of the pulmonary lesion. 

When resolution occurs in the affected part, crepitation returns, coarser 
and more like bubbling than before ; the breath-sound becomes less high- 
pitched and metallic, and gradually loses its blowing quality. The dulness 
also diminishes and finally disappears. Be turning crepitation is often 
absent in the child, and resolution frequently takes place without any 
moist rhonchus being heard. The excessive resonance of the voice and cry 
usually persist over the affected spot for some time, or until the consolida- 
tion has completely disappeared. Resolution is carried on more rapidly in 
some children than in others. In many cases, however, when dulness per- 
sists for some weeks after subsidence of the general symptoms, the impair- 
ment of the percussion-note is due to a layer of lymph over the pleura at 
the affected spot. 

The physical signs just described usually occupy the lower two-thirds 
of one side ; but may be found at any part of the lung. Often they are 
confined to the apex ; or may be discovered over a limited area under one 
of the arms. As has been already observed, they are often slow to de- 
velope ; and therefore, when from the general symptoms croupous pneu- 
monia is suspected, frequent and complete examination should be made 
until the situation of the local lesion is discovered. An important pecu- 
liarity of this form of disease is that the physical signs, unless situated at 
the apex of the lung, are usually confined to one aspect of the chest. If 
they are detected at the posterior aspect, the signs are normal in front ; 
while inflammation of the anterior part of the lung produces no alteration 
of resonance or respiratory sound at the back of the chest. Therefore a 
complete examination of the chest must be made before we are justified in 
saying that no signs of pneumonia are present. 

Terminations. — In the large majority of cases in the child croupous 
pneumonia ends in resolution and recovery. In the primary form of the 
disease an unfavourable termination is very rare ; and even in cases of sec- 
ondary pneumonia, unless the child be a new-born infant or in a state of 
great weakness, it is exceptional for him to die. When death takes place 
it usually occurs on the fourth or fifth day as a result of failure of the 
heart. It may, however, happen later as a consequence of abscess or 
gangrene of the lung. 

When resolution occurs, the improvement is very sudden, and the dis- 



CROUPOUS PNEUMONIA — SYMPTOMS. 429 

ease terminates by crisis. The temperature, which had given little or no 
sign of reduction, falls suddenly in the course of twelve hours to the normal 
level, and remains low for four-and-twenty hours, even if it afterwards 
undergo a moderate increase. The crisis often occurs on the fifth day, 
but may be deferred until the eighth or ninth, and in rare cases until 
later. The violence of the onset, the height of the fever, and the severity 
of the nervous symptoms are not in proportion to the extent of surface in- 
volved, nor are they to be taken as an indication that the course of the 
disease will be prolonged ; for cases in which the general symptoms are 
very pronounced may come to an end on the fifth day. The cessation of 
the pyrexia is followed by an immediate improvement in the child's con- 
dition. The skin becomes moist ; the tongue cleans ; the pulse and respi- 
ration fall in frequency and regain their normal relation to one another ; 
the cough is loose and less frequent ; the urine is more profuse ; and the 
appetite returns. The favourable change in the general symptoms precedes 
the improvement in the physical signs, and for a day or two the resonance 
may continue to be impaired, and the breathing to be bronchial or blow- 
ing over the affected part of the lung. 

In exceptional cases the termination by resolution occurs more gradu- 
ally. The temperature perhaps falls suddenly, but almost immediately 
rises again ; so that for two or three days, a week, or even longer, the 
bodily heat may continue to be considerable at night, with a morning fall. 
Sometimes, after remaining low for two or three days the thermometer 
again registers a high degree of temperature and the child passes through 
a complete relapse of his illness. The relapse is, however, usually shorter 
and less severe than the original attack. 

The termination by abscess of the lung is not often seen except in cases 
where the pulmonary affection is secondary to pyaemia. It does, however, 
occasionally occur in children of weakly constitution who are living in 
thoroughly insanitary conditions ; and may also be seen in cases where in- 
flammation is set up in the lung as a consequence of impaction of a foreign 
body in one of the bronchi. 

When abscess of the lung occurs in a case of secondary pneumonia the 
temperature remains high, or if it fall, rapidly rises again and assumes a 
hectic type ; there is great weakness ; the tongue becomes dry and brown, 
and the complexion dull and earthy in tint, with livid discolouration of the 
eyelids and lips. On examination of the chest the dulness is found to per- 
sist, and the breathing to be bronchial or blowing, with much large bub- 
bling or even metallic rhonchus. Unless the abscess burst into a bronchial 
tube, and its contents be evacuated, the physical signs are not characteris- 
tic of the lesion. If, however, the purulent contents are discharged, caver- 
nous breathing, whispering bronchophony, and the usual signs of a cavity 
may be detected at the seat of the disease. If the abscess be the result of 
pysemic infection, the general symptoms are those of the constitutional 
state, and the local signs, not being the consequence of any extensive local 
inflammation, may be overlooked, more especially as the abscesses are small 
and are often completely surrounded by healthy lung-tissue. 

Gangrene of the lung will be considered in a separate chapter. 

Pneumonia is occasionally latent. This form of the disease is most 
commonly seen when the patient is a young child worn and wasted by 
chronic abdominal derangement, whose nervous irritability is almost com- 
pletely lost. In such cases the ordinary symptoms of invasion are not no- 
ticed. There is no sign of pain in the chest. Even the cough may be 
infrequent or absent. A slight rise in the temperature, increased rapidity 



430 DISEASE IN CHILDEEN. 

of breathing, perversion of the pulse-respiration ratio, and indications of 
early prostration may be the only symptoms excited by the intercurrent 
malady. 

Complications. — Inflammation of neighbouring tissues often complicates 
a case of pneumonia. In the child a certain amount of bronchitis is a com- 
mon feature of the illness. In almost all cases we can detect some sonoro- 
sibilant rhonchus not only in the affected lung but also on the opposite 
side of the chest. In many instances there is also some moist rhonchus. 
As a rule the amount of bronchitis is trifling, and the complication is rarely 
sufficiently marked to be a source of danger. 

Plastic pleurisy may also accompany the pulmonary inflammation, and 
sometimes there is a moderate liquid effusion. The pleurisy is seldom of 
much moment, and absorption usually occurs rapidly when resolution of 
the inflammation has taken place. As has been before remarked, the per- 
sistence of dulness over the seat of disease during convalescence is com- 
monly due to the presence of a layer of lymph upon the pleural lining of 
the chest. 

Pericarditis is sometimes induced by extension of the inflammation ; 
but this complication is less common in pneumonia than in the case of 
pleurisy. In the child the inflammation of the pericardium, when it occurs 
in the coarse of a croupous pneumonia, is usually plastic, and is but rarely 
accompanied by effusion. In regard to prognosis it is probably of small 
importance. 

Jaundice is sometimes seen, and is usually mild. It is due to pressure 
upon the bile-ducts by hypersemic portal vessels, the circulation through 
the liver being impeded owing to the condition of the lung. It may also 
arise from gastro-duodenal catarrh. If this be sufficiently intense to create 
an impediment to the introduction of nourishment, the consequences 
may be serious. Gastric or intestinal catarrh may be present without 
jaundice. Diarrhoea is a symptom not unfrequently seen at the begin- 
ning of an attack of pneumonia. As a rule, the purging is not excessive, 
and ill consequences rarely follow from the intestinal derangement. 

Diagnosis. — In a well-marked case of croupous pneumonia the diag- 
nosis is not difficult. The sudden occurrence of high fever, headache, pain 
in the side, short hacking cough, perverted pulse-respiration ratio, and 
rapidly increasing muscular weakness is very suggestive of this disease. 
It is important to bear in mind the nervous symptoms which often accom- 
pany the onset of the illness, or we may alarm ourselves with suspicions that 
an inflammatory head affection is about to manifest itself. But although 
a feverish child is often light-headed at night, and winders somewhat 
in his talk, high fever with early and marked delirium is not a common 
occurrence; indeed, this combination breaking in upon a state of health, if 
combined with a short hacking cough, is almost peculiar to pneumonia. 
If, in addition, we notice that the nares dilate at each inspiration, and that 
the breathing is quickened out of proportion to the pulse, we are justified 
in entertaining the strongest suspicions that the attack is one of croupous 
inflammation of the lung. 

In some cases cough is absent, or is so slight that it passes quite unno- 
ticed, and the nares are motionless in inspiration. Still, the sudden occur- 
rence of a high temperature, with pungent heat of skin, as estimated by 
the hand, combined with early delirium, should suggest the presence of 
pneumonia. In all such cases the chest should be minutely examined for 
confirmatory evidence. It must be remembered that the physical signs are 
often slow to appear, and that forty-eight hours, or even three or four days, 



CROUPOUS PNEUMONIA — DIAGNOSIS — PROGNOSIS. 431 

may pass without any consolidation of the lung being discovered. It must 
also be remembered that the severity of the symptoms is not in proportion 
to the extent of lung-tissue involved, and that after a violent onset the 
local signs may be confined to a mere patch of solidification at any part of 
the pulmonary surface. We must not, therefore, content ourselves with a 
cursory examination of the bases of the lungs. Careful attention must 
also be directed to the apices, and we must not forget to search the axillae 
on either side for evidence of disease. In cases of pneumonic consoli- 
dation the dulness is not complete, and is accompanied by little increase 
in resistance. Moreover, in the large majority of cases the signs are 
limited to one aspect of the chest. Sometimes a faint vibration of the 
chest-wall, inappreciable upon the healthy side, may be detected over the 
seat of disease when the child speaks or cries. 

The combination of high fever, headache, and diarrhoea may be per- 
plexing. If the patient be an infant, the symptoms may be ascribed to 
teething, and the condition of the lung may be overlooked. The nares, 
however, act, and the respiration, if counted, will be found to be hurried 
out of proportion to the pulse. If a physical examination be made, as it 
ought to be, a matter of routine, the nature of these cases will not escape 
recognition. In an older child the same combination of symptoms would 
suggest enteric fever. But the violent onset, the flushed cheeks, the active 
nares, the rapid breathing, the hacking cough, are very unlike the begin- 
ning of enteric fever ; and if delirium come on, it begins very early (on 
the first or second day) in pneumonia, while in typhoid fever it is rarely 
seen before the end of the first week. 

In young children, in whom the disease may begin with violent convul- 
sions, or with a drowsiness approaching to stupor, the diagnosis is very 
difficult, especially as there is often no cough. Usually until signs of con- 
solidation are discovered at some part of the chest the nature of the illness 
must remain doubtful. Still, drowsiness and a temperature of 103° or 
104°, without signs of severe headache, but with rapid, regular, breathing, 
a perverted pulse-respiration ratio, and pungent heat of skin should suggest 
the presence of pneumonia. 

In the latent form, which usually occurs in wasted children, rapid breath- 
ing and active nares ought always to lead us to make careful and repeated 
examination of the chest. 

The distinguishing marks of catarrhal pneumonia and collapse of the 
lung are considered in the chapters treating of those subjects. 

Prognosis. — Primary croupous pneumonia, unless very extensive, almost 
always terminates favourably, and even in infants is seldom dangerous. 
Resolution takes place early, as a rule, and the consolidation clears com- 
pletely away, leaving the lung as sound as before. The situation of the 
local lesion has no influence upon the prognosis, and no special danger is 
connected w T ith inflammation of the apex of the lung. The nervous symp- 
toms, however serious they may appear, need cause no alarm, for they sub- 
side altogether when consolidation becomes established. Delirium in itself, 
without other signs of nervous disturbance, is rarely an unfavourable symp- 
tom in a feverish child. It usually disappears after a few days, but may 
return again towards the end of the disease as a result of weakness ; but 
this recurrence, if the indication which it furnishes is attended to, is rarely 
followed by dangerous consequences. 

The secondary forms of pneumonia are more serious than the primary, 
for the tendency to failure of the heart's action is increased by weakness 
induced by previous disease. So, also, the existence of a depressing com- 



432 DISEASE IN CHILDREN. 

plication adds to the danger of the case. Pneumonia occurring in the 
course of Bright's disease is an especially serious form of the complaint. 

A very rapid pulse (over 140) is an unfavourable sign, especially if 
the pulsations are irregular in force and rhythm. So, also, a rise of 
temperature above 105° should be regarded with anxiety, although in 
early life this phenomenon is less serious than a similar elevation would be 
in the case of an adult. 

Treatment. — In an ordinary case of primary croupous pneumonia little 
is required beyond keeping the child quiet in bed in a well ventilated 
room, wrapping the affected side of the chest in cotton wool or linseed 
meal poultices frequently renewed, and administering a simple effervescing 
saline or other febrifuge draught several times in the day. The pain in 
the side is usually greatly relieved by the use of hot poultices and other 
applications. To be efficient, however, these should be used as hot as the 
skin can bear them ; and dry heat, such as a bag filled with heated bran or 
salt, is perhaps better — it is certainly more manageable — than hot flannels. 
If any severe pain is complained of, a proportion of mustard (one-fifth or 
one-sixth) may be added to the poultice, and this may be allowed to remain 
for six or eight hours in contact with the skin. If the cough is distressing 
a few drops of ipecacuanha wine and of compound tincture of camphor 
may be included in the mixture ; and a few drops of antimonial wine may 
be added with advantage on account of its diaphoretic action upon the 
skin. The old plan of attempting to reduce the inflammation by large 
doses of antimony is one to be very strongly deprecated. If the bowels 
are confined, or the complexion has a sallow cast and there is tenderness 
over the liver, an aperient powder should be prescribed, such as a grain of 
calomel with two or three grains of jalapine ; but the aperient seldom re- 
quires repetition. Violent purgation in this disease is decidedly injurious. 

The diet should consist of meat broths and milk until the consolidation 
is complete. When the establishment of blowing breathing and the dis- 
appearance of crepitation show that the process of repair is about to begin 
the diet can be improved. Strong beef-tea should then be given at proper 
intervals, and a yolk of egg may be added to the diet. The thirst may 
be relieved as often as the child requires drink, but he must not be 
allowed to take a large quantity of fluid at one time. In the case of an 
infant at the breast, or one who is brought up by hand, some thin barley- 
water should be given from time to time to relieve thirst, so that the 
quantity of food the child takes may be restricted. 

If the pyrexia rise to a high level and the child seem distressed by the 
intensity of the fever, the temperature may be reduced by sponging the 
surface of the body with tepid water ; or if absolutely necessary, the child 
may be placed in a tepid bath of the temperature of 70°. If, however, the 
bath be used, great care must be taken not to depress the child, as failure 
of the heart's action is one of the dangers to be apprehended in cases of 
pneumonia. Both before immersion and after removal from the bath a 
stimulant should be given, and if the feet feel cold, a hot bottle should be 
put into the bottom of the cot. Quinine is strongly recommended 
by some authors as a valuable remedy at an early period of the illness. 
It is given partly as an anti-pyretic, for it is said quickly to reduce the 
temperature without weakening the heart ; partly for its supposed influence 
in checking the spread of the disease over the lung. To be of service as 
an anti-pyretic the drug must be given in full doses ; and it must be 
remembered that children bear the remedy well. For an infant of twelve 
months one grain should be administered three times a day. This 



CKOUPOTJS P^EUM01S T IA — TREATMENT. 433 

quantity can be increased by one grain and a half for every year of the 
child's life. Aconite and other depressing anti-pyretic drugs are dangerous 
remedies to employ in cases of pneumonia on account of their weakening 
influence on the heart. 

In cases where great dyspnoea and threatened cardiac failure arise from 
over-distention of the right side of the heart, it becomes a serious question 
whether abstraction of a small quantity of blood is not called for. If the 
danger is imminent I should not hesitate to take one, two, or more ounces 
of blood from the arm. Life can often be saved by this means. Even 
while the blood is flowing the inspirations become slower and quieter and 
expand the chest more fully ; the pulse gains in fulness and force ; and 
the anxiety and feeling of oppression subside. I can look back upon 
several fatal cases which I now believe might have been saved had I had 
the courage to relieve the labouring heart by the judicious removal of 
blood. It is in such cases alone that bleeding is justiiiable in this disease ; 
and here the treatment is directed not against the inflammation, but against 
one of its consequences, viz., the overtaxing of the heart by the impedi- 
ment to the pulmonary circulation. 

It is not often that stimulants are required in cases of primary pneu- 
monia in children, but if the disease is secondary they may have to be 
resorted to. Great rapidity of the pulse is an indication for stimulants 
which must not be disregarded ; and if a pulse of 140 is found to be inter- 
mittent in force and rhythm, doses of egg-and-brandy should be given at 
regular intervals until improvement occurs. 

Delirium at the beginning of the disease, if noisy, may be usually 
quieted by tepid sponging of the surface of the body. If necessary, a 
small dose of Dover's powder can be given at night. Chloral, on account 
of its depressing effect, must not be used. If delirium occur later in the 
illness it is a sign of debility, and energetic stimulation will be required. 
Sleeplessness can also be usually removed by tepid sponging in the evening. 

If diarrhoea occur, it may often be promptly checked by a dose of castor- 
oil or of rhubarb (gr. iij.-v.), with double the quantity of the aromatic chalk 
powder given every night. Astringents are rarely necessary in these cases ; 
but if the purging continue, sal volatile may be given with spirits of 
chloroform and a drop or two of laudanum, according to the age of the child, 
three or four times a day. A layer of cotton wadding should be applied 
to the belly under a flannel binder for the sake of warmth ; and food 
should be given in small quantities at a time. 

Directly the temperature falls tonics should be given ; and the diet of 
health may be returned to ; taking care that the food is digestible in kind, 
and that it is given in quantities suitable to a convalescent. 
. 28 



CHAPTER V. 

CATARRHAL PNEUMONIA. 

Catarrhal or lobular pneumonia, or broncho-pneumonia, is the common 
form of inflammation of the lung met with in infancy, and is frequently 
seen in early childhood. The disease is quite distinct from the croupous 
form previously described, differing from it in its pathology, its symptoms, 
and its tendency to end in death. Catarrhal pneumonia is nearly alwaj-s 
a secondary affection, and results from spread of inflammation from the 
bronchial mucous membrane to the alveoli. Consequently, the disease 
invariably attacks both lungs, although it may be more extensive on one 
side of the body than on the other. 

Causation. — As broncho-pneumonia is always preceded by pulmonary 
catarrh, the causes which induce bronchitis in the child may be looked 
upon as tending in a great measure to set up catarrhal pneumonia in the 
air-vesicles. These are especially cold and damp, and the inhalation of dust 
and other irritating particles in the air. 

A severe bronchitis in the young child always inclines to spread to the 
finer tubes and air-cells ; but certain forms of illness have great influence 
in determining the extension of the inflammation. Thus, measles and 
whooping-cough number lobular pneumonia amongst their most frequent 
sequela?, and the disease is also common as a secondary consequence of 
diphtheria. In scrofulous and tubercular subjects, and even in children 
who are merely weakly and under-nourished, lobular pneumonia is readily 
excited. Therefore any influence which diminishes the resisting power of 
the child and lowers his general health must be looked upon as a predis- 
posing cause of the complaint. Thus, bad feeding, insanitary conditions, 
and depressing derangement or disease may all help to induce this form of 
pneumonia. It is very common in the case of young children for the 
illness to be preceded by a history of more or less persistent diarrhoea. 
A young child who is subject to attacks of intestinal catarrh becomes 
excessively sensitive to chills, and after a time acquires a catarrhal propen- 
sity which, combined with the weakness induced by the digestive derange- 
ment, is likely to result in an attack of catarrhal pneumonia. Neglected 
colds on the chest may set up broncho-pneumonia in the most robust 
subjects ; but amongst the well-to-do classes it is comparatively rare to find 
this disease in children who are not strumous or delicate, or rickety, or who 
have not been lately suffering from an attack of measles or whooping- 
cough. 

Morbid Anatomy. — Lobular pneumonia may arise as a consequence of 
direct extension of the inflammation from the larger tubes to the smaller, 
and thence to the air-cells ; or may occur secondarily to collapse of the 
lung. In the infant the latter is the method in which the disease usually 
originates, for in such young subjects, on account of the narrowing of the 
bronchial tubes, the feeble inspiratory power, and the normal softness and 



CATARRHAL P^ETTMOXIA — MORBID ANATOMY. 435 

compressibility of the chest-walls, collapse of the lung is a very common 
consequence of pulmonary catarrh. The special tendency of rickets to be 
complicated by bronchitis and catarrhal pneumonia has been elsewhere 
referred to. The difficulty of expanding the chest in this disease, owing to 
the softening of the ribs, greatly contributes to setting up collapse of the 
lung ; and any additional impediment, such as a catarrhal state of the 
bronchial membrane, promotes the exhaustion of the air-cells. Collapse of 
the lung is followed by congestion of the small vessels, owing to the 
impediment created by imperfect aeration of the blood, and to the absence 
of the exj>ansion and contraction of the air-cells, whose movement in a state 
of health materially advances the pulmonary circulation. As a result of 
congestion of vessels there is oedema which causes great diminution in the 
consistence and cohesion of the tissue at the affected spot. In this state 
the part is ready for the development of inflammatory changes. Inflam- 
mation readily extends to it from the air-tubes ; or the irritation induced 
by the penetration into it of secretion from the bronchial mucous mem- 
brane excites the inflammatory process. 

Lobular pneumonia usually begins in isolated groups of vesicles, being 
often determined by the presence in them of inflammatory products drawn 
from the small tubes with which they are in communication. On inspec- 
tion of the lungs we see scattered nodules of consolidation of a reddish 
gray colour scattered over the surface. They vary in size from a small pea 
to a nut Their consistence is friable, their substance smooth or faintly 
granular, and their circuniference ill-denned. As the process advances, the 
nodules which were at first isolated become united at their borders so as to 
produce considerable tracts of consolidation ; and at the same time the 
solidified parts become firmer, dryer, and of a yellowish gray colour. In 
then' centres we can sometimes see divided air-tubes filled with purulent 
matter. 

The lung-tissue in which the nodules are embedded exhibits collapse, 
congestion, oedema, and emphysema in various stages and degrees. A 
certain amount of dilatation of vesicles is almost invariably present in the 
neighbourhood of collapsed portions of lung, and there is, moreover, an 
appreciable degree of cylindrical dilatation of all the minuter bronchi, 
especially of those portions which immediately adjoin the terminal alveoli. 
The walls of these tubes are excessively attenuated. The dilatation appears 
to be the consequence in some cases of accumulation of secretion. In 
others it is due to diminution of the respiratory surface, for plugging of 
some tubes with mucus causes an increased rush of air to the parts which 
still remain pervious. 

The consolidating matter itself consists in a very small degree of ex- 
uded corpuscles, as in the case of croupous pneumonia. On examination 
the alveoli will be found to be stuffed with cells, but these are in great 
part derived from proliferation of the epithelial lining of the vesicles. Mixed 
up with these epithelial elements are leucocytes and much gelatinous mu- 
coid matter — probably secretion from the inflamed bronchial mucous mem- 
brane which has been drawn into the alveoli. In all cases of catarrhal 
pneumonia large quantities of thick puriforrn bronchial secretion are found 
filling the air-cells and plugging the finest tubes. When this is very copi- 
ous the amount of epithelial cells is comparatively insignificant. Thus, 
some of the nodules of consolidation appear to be composed almost exclu- 
sively of thick bronchial secretion ; and a microscopic examination shows 
very few proliferated cells and little change in the epithelial lining of the 
alveoli. In other parts the nodules are composed almost entirely of epi- 



436 DISEASE IN CHILDREN*. 

thelial elements, and the epithelium lining the alveolar walls is swollen, 
granular, and partially detached. 

These lesions are found in both lungs ; and the process begins in the 
most depending part, i.e., in the lower lobes at the posterior aspect ; for 
gravitation greatly aids the passage into the cells of these parts of purulent 
secretion descending from the tubes. The extension of the inflammation 
laterally is always irregular, and the selection of the lobules for attack ap- 
parently capricious ; for while some become consolidated, others in imme- 
diate contact with them remain healthy or merely congested. The nodules 
and patches of solidification are at first isolated, but tend to coalesce, and 
in the latter period of the disease comparatively wide areas of consolida- 
tion may be found. 

The pleura in the neighbourhood of the spots of consolidation is red- 
dened with points of ecchymosis, and adhering to it is often a little plastic 
lymph. 

If the case do not terminate unfavourably, resolution usually ensues. A 
process of fatty degeneration takes place in the contents of the alveoli. 
The consolidating material becomes softened down and is removed more or 
less rapidly by absorption and expectoration. The process of resolution 
often occupies some time even when the lung finally returns to a normal 
condition. Often, however, the process of fatty metamorphosis becomes 
arrested. The cells then atrophy and become caseous, and a chronic con- 
solidation is left which forms one of the varieties of pulmonary phthisis. 
In other cases an indurative pneumonic process is set up which leads to a 
great development of fibroid tissue in the part. The walls of the air-tubes 
and the alveoli become thickened and indurated and the tubes dilated. 
This condition forms a special variety of lung disease which will be after- 
wards described (see fibroid induration of the lung). 

Symptoms. — Broncho-pneumonia is a secondary disease. Its symptoms 
are always preceded by those characteristic of a more or less severe pul- 
monary catarrh. In weakly, ill-nourished children, especially if they are 
suffering from an attack of measles, a comparatively trifling catarrh will 
set up lobular inflammation of the lungs. In a robust child inflammation 
of the alveoli seldom ensues unless the preliminary catarrh has been long 
continued or very severe. When broncho-pneumonia follows an ordinary 
catarrh of the lungs, the disease usually runs a very acute and rapid course 
and commonly ends in death. When it arises in the course of an attack of 
measles or whooping-cough the complication is more subacute in charac- 
ter and the proportion of recoveries is greater. Still, such cases tend to 
leave unabsorbed deposits in the lungs. 

After the symptoms of pulmonary catarrh have continued for some time 
they suddenly change their character. The temperature rises ; the cough 
becomes short and hacking ; the pulse and respirations are hurried ; the 
face is more or less livid ; the nares act ; and in the infant a well marked 
labial line becomes developed, passing from the angle of the mouth down- 
wards and outwards to the ramus of the lower jaw. 

The pyrexia varies in degree. In children in whom an ordinary bron- 
chitis gives rise to fever, the temperature, when inflammation of the lung 
is superadded, may reach a high level. Thus, the thermometer may mark 
104° or 105°, but undergoes more decided variations during the twenty- 
four hours than is the case in croupous pneumonia. In most instances there 
is a decided remission between 6 a.m. and noon ; the chief elevation occur- 
ring between 10 p.m. and 3 or 4 a.m. Sometimes, however, for twenty-four 
or forty- eight hours the temperature may remain at about the same level, 



CATAEEHAL P^EUMO^IA — SYMPTOMS. 437 

varying only by half a degree. In spite of the pyrexia the skin is often 
moist, and in some cases perspiration is profuse. 

In catarrhal as in croupous pneumonia the pulse-respiration ratio is 
perverted ; but the disproportionate rapidity of the breathing is variable 
according to the acuteness of the case In the severe acute variety the 
ratio may be 1 to 2 or even 1 to 1.5 ; while in the subacute form the ratio 
may be only 1 to 2.5 or 3. The pulse is very rapid (120 to 150, or even 
higher), but is small and feeble, for the impediment to the passage of blood 
through the lungs obstructs the whole circulation. Consequently the ar- 
teries are comparatively empty, while the venous system, as is shown by 
the fulness of all the superficial veins, is congested. 

The breathing besides being hurried is laborious, and there is evident 
dyspnoea. The child often cannot lie down in bed and has to be supported 
by pillows. At each inspiration the nares dilate widely, and the shoulders 
rise with the laboured action of the accessory muscles. Often the child 
endeavours to aid the expansion of his chest by grasping tightly the bars 
of his cot. Still, with all his endeavours the patient is unable to fill his 
lungs with air, for at each movement of the chest the intercostal spaces and 
supra clavicular hollows become depressed, the epigastrium sinks in, and 
the lower ribs are retracted. 

The cough, when the air-cells become attacked, changes its character 
and seems painful. This change in the cough is a very valuable sign. In- 
stead of the prolonged, rather paroxysmal cough of bronchitis, we hear 
the short hard hack of pneumonia ; and this may be repeated with each 
expiration for many minutes together, causing great distress and exhaus- 
tion. 

Looseness of the bowels is a common symptom, the stools being slimy 
and thick, or thin and watery. Vomiting, induced by the cough, is also 
often present ; and much mucus is discharged both from the stomach and 
lungs. Nervous symptoms are sometimes noticed. In an uncomplicated 
case convulsions do not occur in the course of the illness, although they 
may be present shortly before death when asphyxia is imminent ; but twitch- 
ings and spasmodic movements of the muscles of the eyeball are often 
seen during sleep. 

At this time a physical examination of the chest discovers merely the 
signs of bronchitis ; for the consolidation being limited to small scattered 
nodules and surrounded by emphysematous air-cells, can rarely be 
detected by percussion. Sometimes, however, by employing broad 
percussion, i.e., by striking with three fingers on three fingers applied 
to the chest-wall as pleximeters, we notice some diminution of healthy 
pulmonary tone ; and in some cases a careful exploration distinguishes 
certain spots where there is more evident' diminution in resonance, and 
perhaps bronchial breathing over the same limited area. If the pneu- 
monia occurs in collapsed portions of lung we can often find at each base 
a pyramidal strip of dulness reaching upwards for a certain distance, when 
percussion is made very lightly. With the stethoscope general fine bub- 
bling rhonchus is heard, and in certain spots this will be noticed to be 
finer, dryer, and more crepitating in character. This crepitating quality 
is especially noticeable over an area where the breathing is bronchial ; for 
unlike croupous pneumonia, the crepitus is not lost when consolidation oc- 
curs. 

As the illness advances, and the nodules of consolidation grow larger 
and coalesce, more and more of the respiratory surface becomes involved, 
so that cyanotic symptoms are manifest. The face grows excessively 



438 DISEASE IN CIIILDEEN. 

pale, with a dusky tint around the eyes and mouth ; the expression is 
anxious ; the eyeballs are staring and suffused. The respirations may 
rise to 70, 80, or even more in the minute ; and the breathing grows 
more and more laborious. The child is painfully apathetic and dulL 
If an infant, he refuses his bottle, and can with difficulty be per- 
suaded to swallow fluids from a spoon. His hands and feet are purple and 
often cold to the touch, although the internal temperature of the body is 
still febrile. At this period cough almost ceases, partly from exhaustion, 
partly from impaired irritability of the respiratory centre. In this state 
the child sinks and dies, the end being often preceded by a fit of convul- 
sions. Before death, when this takes place from asphyxia, the internal 
temperature may be subnormal. In the case of a little rickety boy, aged 
thirteen months, with only two teeth, who died on the eleventh day from 
extensive catarrhal pneumonia of both lungs, the temperature at 6 p.m. 
on the evening before death had fallen to 98° in the rectum. 

At this stage of the disease percussion discovers more or less extensive 
dulness of the back on each side ; and the breathing is bronchial or tubu- 
lar, especially about the angle of the scapula. The respiration is accompa- 
nied by much fine metallic crepitation both in inspiration and expiration ; 
and this is often very superficial-sounding, as if generated immediately 
underneath the stethoscope. In the front of the chest there is seldom 
dulness, unless perhaps the resonance at the bases is diminished ; but 
usually a certain amount of coarse crepitation may be heard in the mam- 
mary and infra-mammary region on each side. A curious feature at this 
time is the indifference of the child to the discomforts of the examination. 
He allows himself io be placed in any position without complaint, and 
seems to be quite careless what is done to him. 

If the disease terminate favourably, there is no critical fall of temper- 
ature, as is the case with the croupous variety of pneumonia. On the con- 
trary, the diminution in the pyrexia takes place very gradually, and the 
improvement in the general condition does not occur until the local symp- 
toms have given signs of amendment. Thus, the pulse and respiration 
are reduced in frequency, the breathing becomes less laborious, the pulse 
fuller, and the superficial veins less distended. The pallor and lividity 
of the face are less noticeable and the expression loses its distress. The 
tongue cleans, vomiting ceases, and the appetite returns. Still, the tem- 
perature, although it continues to fall, is some days before it sinks to a 
natural level. The physical signs are also very slow to improve, and ab- 
sorption takes place very gradually. This variety of pneumonia, as has 
been said, is apt to leave behind it caseous unabsorbed masses in the lung 
which may lead to serious illness in the future. Still, under favourable con- 
ditions these often become absorbed even although a period of months has 
ek/psed since the attack was at an end. 

If the disease do not prove fatal or show signs of resolution at the end of 
a week or ten days, it often takes on a subacute course. In some cases, espe- 
cially where the catarrhal pneumonia occurs as a complication of measles 
or whooping-cough, the subacute character may prevail from the first. 
In this form the symptoms are less severe than in the acute variety, and 
the course of the disease is much longer. The temperature does not reach 
so high a level, remaining usually at about 102°, with morning remissions. 
Sometimes the pyrexia undergoes curious alternations. Thus, after being 
moderate for a few days (99°-101°) the temperature suddenly shoots up to 
104° or 105°, and after a day or two sinks again to the same level as be- 
fore. The pulse and respiration are both hurried, but their normal rela- 



CATAERHAL PNEUMONIA — COMPLICATIONS— DIAGNOSIS. 439 

tion is comparatively little altered. As tlie disease advances the cough 
loses its hacking character and occurs in violent paroxysms almost indis- 
tinguishable from those of pertussis. Their duration is, however, shorter, 
and inspiration is noiseless or less decidedly crowing. They may be fol- 
lowed by vomiting. This character of the cough should lead us to sus- 
pect considerable dilatation of the bronchi. 

Vomiting and some looseness of the bowels are common symptoms. 
The tongue is furred ; the appetite is impaired ; the strength is diminished ; 
and the child wastes rapidly and becomes very feeble. In these cases, in 
addition to the physical signs of broncho-pneumonia which have been 
already described, we find very clear evidence of dilatation of bronchi. At 
each posterior base, but more pronounced on one side than on the other, 
cavernous breathing is heard with a coarse metallic ringing crepitation, 
sounding very close to the ear ; or the respiratory sound may be amphoric 
with tinkling echo. In many cases, too, the vocal resonance is broncho- 
phonic, and the faintest laryngeal sound is conducted clearly to the end of 
the stethoscope. 

These cases often continue for weeks, but under judicious treatment 
generally end in recovery. There is, however, a great tendency to imperfect 
absorption of the deposit ; and unless the child be placed under favoura- 
ble sanitary conditions a chronic consolidation may be left which is after- 
wards a source of danger, Sometimes, too, these cases pass into fibroid 
induration of the lung. 

Complications. — The complications of simple catarrhal pneumonia are 
not numerous. The illness sometimes begins with stridulous laryngitis, 
and in the rare cases where the spasmodic disease ends fatally death is 
usually due to the presence of the pulmonary inflammation. Gastric and 
intestinal catarrh have already been mentioned as frequent complications 
of the pneumonia. In the child a catarrh is seldom simple ; often several 
tracts of mucous membrane share in the derangement. 

Catarrhal pneumonia is itself also a common complication of other 
forms of illness. Measles, whooping-cough, and rickets have already been 
referred to. General tuberculosis in many, perhaps in most, instances 
becomes complicated with this form of pulmonary inflammation ; and 
in the case of fibroid induration of the lung the danger of the disease 
consists in a great measure in the repeated attacks of catarrhal pneu- 
monia to which children with this form of lung affection are peculiarly 
prone. 

Diagnosis. — At the beginning of the illness we have to found our diag- 
nosis upon the general symptoms alone, for there is at first no sign of 
consolidation, and physical examination of the chest only reveals the pres- 
ence of severe bronchitis. Mere elevation of temperature is no proof that 
the inflammation has spread to the alveoli, for in many children — especi- 
ally those with scrofulous tendencies— a pulmonary catarrh is accompanied 
by moderate pyrexia. If, however, the temperature reach 104° or 105 ? ° 
and at the same time the cough get suddenly short, hacking, and painful, 
while the breathing becomes disproportionately quickened so as to cause 
notable perversion of the pulse-respiration ratio, this combination of 
symptoms is very suggestive of catarrhal pneumonia. A perverted pulse- 
respiration ratio alone is not characteristic, for this may occur in cases of 
collapse of the lung. Still, if with great hurry of breathing we find the 
respiratory movements laborious, and notice that the soft parts of the chest 
recede deeply at each breath, the sign is in favour of pneumonia ; for in 
pulmonary collapse the breathing, although excessively hurried, is shallow, 



440 DISEASE IN CHILDREN. 

and unless the ribs are much softened from rickets the recession at the 
base of the chest is slight. 

Quite at the beginning of the illness it may be difficult to distinguish the 
disease from the croupous form of pneumonia where the signs of consolida- 
tion are delayed. At this time the age of the child, the history of the attack, 
and the character of the breathing are important points of distinction. 
In an infant the inflammation is probably catarrhal, and if the child is frail 
or badly nourished, is almost certainly so. The history of previous cough 
points strongly to the lobular form ; and laborious breathing, great reces- 
sion of the chest- walls in inspiration and a very evident feeling of dyspnoea 
are distinctive of catarrhal rather than of croupous pneumonia. The latter 
disease rarely attacks a feeble, ill-nourished infant ; it comes on suddenly 
without previous catarrh ; the breathing, although hurried, is not labo- 
rious ; and there is no true dyspnoea, the child not being distressed by the 
recumbent posture. 

When extensive areas of lung have become consolidated, the catarrhal 
origin of the lesion is distinguished by attention to the crepitation. This 
rale in croupous pneumonia ceases to be heard over the solidified area and 
can only be detected at its confines. In catarrhal pneumonia the crepitat- 
ing rhonchus becomes finer and crisper towards the centre of the consoli- 
dation, and is heard with the most typical bronchial or blowing breathing, 
being sometimes, indeed, so copious as almost or entirely to cover the 
breath-sound. Moreover, moist and dry bronchitic rales are heard over the 
lungs generally. In croupous pneumonia this is not often the case, for al- 
though some sonoro-sibilant rhonchus is occasionally present, this is trifling 
in amount, and, as a rule, is not accompanied by moist sounds. 

One of the chief difficulties in the case of catarrhal pneumonia is to ex- 
clude tuberculosis. That we should be able to do so is of the greatest im- 
portance with regard to prognosis ; for while, if the inflammation be uncom- 
plicated, recovery may take place, if the child is tubercular death is certain. 
The subacute form of the disease occurring in a weakly child and accompa- 
nied by diarrhoea and rapid wasting, presents symptoms which are identical 
with those resulting from acute tuberculosis with secondary lung complica- 
tion. The physical signs are also the same, for no additional feature is fur- 
nished by the presence of the gray granulation in the lungs. Family history 
is here of importance. If we can discover that other children of the same 
parents have died with symptoms of tubercular meningitis, the history is 
suggestive of tubercle. If, again, we can learn that before the onset of the 
disease the child was losing strength and growing pale and thin without 
evident cause, the fact is also in favour of tuberculosis. Again, the age of 
the patient must be considered. Over the age of six years catarrhal is less 
common than croupous pneumonia. Therefore, if the catarrhal inflamma- 
tion occurs in a child more than six years old, who has been previously 
wasting without apparent reason, and has not lately suffered from measles 
or whooping-cough, we have here strong evidence in favour of tubercle. Of 
the actual symptoms the only one which in any way points to a constitu- 
tional cause for the illness is the presence of oedema without albuminuria ; 
but this phenomenon, although it may add weight to other evidence, is in 
itself of little value in a weakly child. If, however, any serious symptoms 
arise pointing to the brain, and convulsions occur, followed by squint, 
unequal pupils, ptosis, or rigidity of joints, we can have no hesitation in 
concluding the case to be one of acute tuberculosis. It must be remem- 
bered that terminal convulsions are common in catarrhal pneumonia from 
asphyxia, and are quickly followed by death. But convulsions occurring in 



CATARRHAL PNEUMONIA — PROGNOSIS — TREATMENT. 441 

the course of the illness and not evidently the consequence of impurity of 
blood, are very suspicious of tuberculosis, even although no other sign of 
nerve-lesion be immediately manifested. 

When dilatation of the bronchi occurs in an advanced case of the sub- 
acute variety of catarrhal pneumonia it is important to exclude ulcerative 
destruction of lung. Thus, in the fifth or sixth week of a broncho-pneu- 
monia a child is seen with a temperature of 100° in the morning, rising to 
102° or 103° at night. At the same time an examination of the chest dis- 
covers a fine crepitating rhonchus at the base of each lung, with impaired 
resonance over the lower half posteriorly of each side, and at one basedul- 
ness, loud cavernous breathing, metallic gurgling rhonchus, and broncho- 
phony. These latter signs are evidently significative of a cavity ; but the 
cavity may be a dilated bronchus or a vomica in the lung. To which of 
these causes the physical signs are to be attributed must be decided by 
reference to the general symptoms and the progress of the case. The po- 
sition of the cavity, indeed, at the base of the lung, points rather to bron- 
chiectasis than to a vomica, but this is not conclusive proof. If, however, 
we find that the temperature begins to fall, the child's appetite to return, 
the general nutrition to improve, and at the same time notice that the 
cavernous sounds become less intense, the respiration less shrill, and the 
gurgling less metallic, we may safely infer that no disintegration of lung- 
tissue has taken place. 

Prognosis. — The prospect of the patient's recovery in a case of broncho- 
pneumonia is always doubtful. In new-born infants, indeed, the illness 
almost invariably terminates fatally ; but even up to the end of infancy the 
rate of mortality is very high. When the disease succeeds to measles or 
whooping-cough its course is less acute than when it arises as a consequence 
of simple pulmonary catarrh, and in these cases there is a greater propor- 
tion of recoveries. If, however, the lobular pneumonia come on during the 
spasmodic stage of pertussis, or towards the beginning of an attack of 
measles, it is very commonly fatal. The existence of any debilitating con- 
dition or exhausting disease increases the danger of the case. Thus in 
diphtheria the occurrence of secondary broncho-pneumonia is an event of 
the utmost gravity ; and in rickets the local weakness of the softened ribs, 
combined with the general want of power in the patient, militates power- 
fully against a favourable termination to his illness. The danger is usually 
great in proportion to the degree to which aeration of the blood is inter- 
fered with. Therefore lividity of the face, blueness of the nails, lips, and 
eyelids, smallness and rapidity of the pulse with dilatation of the superficial 
veins, great perversion of the pulse-respiration ratio, suppression of the 
cough, and marked apathy or somnolence are symptoms indicative of serious 
danger. If convulsions occur at a late period of the illness we must prepare 
the child's relatives for the worst. 

Treatment. — The occurrence of catarrhal pneumonia may often be pre- 
vented by judicious treatment of the preliminary catarrh, and especially by 
the employment of energetic measures on the first sign of collapse of the 
lung. This subject is discussed elsewhere. 

When lobular pneumonia has supervened, the indications to be fulfilled 
are three in number. We have to reduce the temperature, to promote ex- 
pansion of the lung, and to support the strength of the patient. 

In order to lessen the temperature tepid bathing is often resorted to. 
The child should be placed in water of the temperature of 70°. In this he 
may remain for ten or fifteen minutes at a time. The bath must be re- 
peated more than once in the four-and-twenty hours, for the reduction of 



442 DISEASE IN CHILDREN. 

temperature is only a passing improvement, and the pyrexia quickly re- 
turns. This method is highly spoken of by Eilliet and Barthez, who rec- 
ommend its employment in every case, unless the prostration of the patient 
be extreme. Another method is that advocated by Bartels. It consists in 
packing the child in a cold, wet sheet, covered with a thick folded blanket, 
for three or four hours at a time. The process in this case also requires to 
be repeated at intervals, so long as no signs of exhaustion are noted, in 
order to maintain the improvement. The effect of either of these measures 
is not only to lessen the fever, but also to increase the depth and reduce 
the frequency of the breathing. 

Another very valuable resource is energetic counter-irritation of the 
skin of the chest. A large poultice of mustard and linseed meal (one part 
of the former to five or six of the latter) should be applied for six or eight 
hours to the back. Afterwards a similar poultice should be allowed to re- 
main for a like time on the front of the chest. On removal of the poultice 
the chest should be covered with cotton-wool. These applications will 
often have to be repeated several times, for in this disease there is great 
tolerance of irritation of the skin even in the case of a young infant. Even 
if the surface is blistered by the application, no harm will be done. 
Indeed, I have been in the habit of ordering the poultices to be continued 
until some signs of blistering of the skin have been noticed. The chest 
can then be covered with cotton-wool. In bad cases, instead of the mus- 
tard poultice, dry cupping of the back is useful. In one severe case of 
this disease — a child of three years of age — I attribute the recovery of the 
patient entirely to the timely use of this energetic application. 

While these methods of treatment are being carried out, the strength 
of the child must be upheld. Stimulants should be given early, and no 
attempt to lower the temperature should be made without at the same time 
administering brandy or the brandy-and-egg mixture. In this disease, as 
in all others which rapidly depress the powers of the joatient, children 
respond well to stimulants ; and alcohol should be given every two or 
three hours, or oftener, according to the strength of the pulse, the rapidity 
of the breathing, and the degree of pallor and lividity of the face. The 
effect of the stimulant is to give strength to the circulation, to reduce the 
number of the respirations and to further the aeration of the blood. If 
the child cannot or will not swallow the remedy, it may be administered, 
as in other exhausting forms of illness, by the syringe and elastic tube (see 
page 15), or through a caoutchouc tube passed into the stomach through 
the nose. 

The diet must consist of milk diluted with barley-water and guarded 
by a few drops of the saccharated solution of lime, of strong beef-tea, 
yolks of eggs, and meat essence. In the case of young infants the breast 
milk, white wine whey, and milk and barley-water with Mellin's Food should 
be given. 

With regard to medicines : — Emetics are useful at the beginning of the 
disease. A drachm of ipecacuanha wine, or half a grain of sulphate of cop- 
per dissolved in a dessert-spoonful of water, may be given every ten minutes 
until vomiting is produced. This remedy must not, however, be repeated 
after the first two or three days, as the strength of the child quickly fails. 
Narcotics are to be avoided, for our object is in every way to promote 
cough in order to maintain efficient expansion of the air-cells and aid the 
expulsion of secretion. The best form of mixture is that which combines 
alkalies with stimulants. Thus, we can order a few grains of bicarbonate of 
soda or potash with four or five drops of sal volatile and an equal quantity 



CATAEEHAL PNEUMONIA— TEEATMENT. 443 

of spirits of chloroform in glycerine and water every three hours. Later, 
the infusion of senega or serpentaria may be substituted for the water in 
the draught. Medication by drugs is, however, as a rule, of very secondary 
importance in the more acute forms of the illness ; but if the disease occur 
as a complication of pertussis, the special antispasmodic treatment for that 
disease may have to be continued. 

When the inflammation runs a very subacute course much benefit is 
often derived from the free administration of iron. For a child five or 
six years old ten drops of the tincture of the perchloride of iron may be 
given every three hours, freely diluted ; and a rapid improvement, both 
in the physical signs and general symptoms, often follows very quickly. 
Directly the pyrexia subsides quinine and other tonics, and cod-liver oil 
should be given ; and the child should be removed, as soon as he is fit for 
the journey, to a bracing seaside air. 



CHAPTER VI. 

PLEURISY. 

Pleukisy is a very common disease in young subjects, and one which, al- 
though seldom immediately fatal, often produces remote consequences of 
a very serious kind. In childhood the effused fluid becomes purulent at a 
very early period ; and the retention in the chest-cavity of a collection of 
purulent matter seriously hinders the nutrition of the patient, and may 
lead to various forms of disease, both general and local. 

Causation. — Pleurisy is comparatively rare during the first twelve 
months of life. It becomes much more common during the second year, 
and after that age is one of the most frequently met with of all diseases of 
childhood. The inflammation may be primary or secondary. In the first 
case it appears to be often the consequence of exposure to changes of tem- 
perature ; at least it is difficult to discover any other cause for it than a 
chill. It may be also excited by mechanical causes, such as direct irrita- 
tion from injury to the chest- wall, or rupture into the chest-cavity of ab- 
scesses or hydatid cysts. Secondary pleurisy may arise from extension 
of inflammation from the lung, the pericardium, or the peritoneum. It may 
occur in the course of acute rheumatism, scarlatina, measles, typhoid 
fever, small-pox, and inherited syphilis ; and is very often a consequence 
of renal disease, and sometimes of tuberculosis. 

Morbid Anatomy. — Inflammation of the pleura is usually confined to one 
side of the chest, and may be general over that side or limited to cer- 
tain regions (localised or loculated pleurisy). The inflammation begins with 
hypersemia of vessels and infiltration of the serous and subserous tissues. 
An effusion of inflammatory lymph then takes place, and of fluid which may 
accumulate to a large amount in the pleural cavity. The serous membrane 
is rough and lustreless, aud becomes coated with a layer of effused lymph. 
This is at first merely a thin, coherent membrane ; but gradually its 
thickness increases. The surface is sometimes ribbed or honeycombed in 
appearance, and we occasionally see strings or bands of lymph passing be- 
tween the opposed surfaces of the pleura, connecting them with one an- 
other. The lymph consists of albumen, fibrine, and corpuscles derived 
from proliferating epithelium. It is at first loosely attached to the serous 
membrane beneath, but gradually becomes more firmly adherent. Event- 
ually new vessels form in it, so that it is organised and converted into con- 
nective tissue. In this way the opposed surfaces become firmly united, 
and the pleural cavity, where these adhesions occur, is obliterated. 

The effused fluid is at first yellowish or greenish, and transparent, but- 
it soon becomes turbid and opaque, and in children very quickly puru- 
lent. The serous effusion contains both albumen and fibrine, and coagu- 
lates spontaneously after removal. The pus is usually quite healthy in 
appearance and without unpleasant smell ; but in exceptional cases it is 
dark coloured and very offensive. Sometimes it is stained or streaked 



PLEURISY — MORBID ANATOMY — SYMPTOMS. 445 

with blood. The quantity of effused fluid is very variable. It may be 
merely an ounce or two, or may reach two or three pints. When thus 
copious, the whole side is dilated, the intercostal spaces are widened, and 
neighbouring organs are displaced. The lung is compressed, and if, as 
sometimes happens, although very rarely in the child, it is bound down by 
a thick layer of false membrane, it may not expand again as the fluid be- 
comes absorbed. In that case it leads to the same deformities as are no- 
ticed under similar conditions in the adult. It is, however, very rare to 
find a greatly contracted chest from an old pleurisy in the child. Even if 
the chest fall in at first, it will be often found to right itself in a surprising 
way in the course of time ; and a child who was left with curved spine and 
retracted ribs may be seen again, after an interval of twelve months, with a 
chest as symmetrical as if it had never been affected. It is rare to find a 
child permanently deformed by this means. 

In some cases the amount of fluid is small. This is most commonly seen 
when the pleural inflammation is secondary to peritonitis, pericarditis, or 
pneumonia. Sometimes the pleural cavity, instead of forming one large ab- 
scess, may be divided into several distinct sacs by false membrane and ad- 
hesions, so that one of these may be emptied without draining the others. 
It is not so very uncommon to meet with more than oneloculated empyema 
in the same subject ; and great difficulty is found in such cases in com- 
pletely relieving the chest of its purulent contents. 

• A large collection of purulent fluid in the pleural cavity rarely becomes 
absorbed. If not removed by operation, a spot at some part of the chest- 
wall — usually the fifth interspace in the inframammary region — is noticed 
to be red and very tender. This soon becomes prominent and forms a 
large superficial abscess, which, if not opened artificially, bursts and the pus 
slowly drains away. By this means caries of a rib is sometimes produced. 
The abscess does not always point low down. It may appear higher up in 
the chest, as above the clavicle, or in an upper intercostal space ; and I have 
known it to open in the supraspinous fossa. In some cases, instead of 
bursting externally, the purulent collection opens into a bronchus and the 
matter is coughed up through the lung. In others it perforates the dia- 
phragm, and passes downwards like a psoas abscess behind the peritoneum. 
Steiner in one case saw it open into the gullet. 

Whether the fluid be removed artificially or escape by perforation of 
the chest-wall, it may after a time drain away completely and leave the 
patient convalescent. Sometimes, however, a discharging sinus is left which 
remains open for years. In these cases amyloid disease of organs often 
follows, or the child may die from general tuberculosis. 

Symptoms. — The onset of pleurisy, although sudden, is not often violent. 
Usually it begins with a feeling of chilliness, or in older children with a 
rigor, and with pain in the side, followed after an interval by cough. It is 
rarely ushered in by a convulsive seizure, as is so commonly the case with 
pneumonia. The pain is often severe. It is felt in the side or is referred 
to the epigastrium or the stomach. In infants who cannot speak, its exist- 
ence is announced by violent fits of crying, which may be excited at once 
by pressure on the chest as in lifting the child up. An older child com- 
plains bitterly of the pain, and often gives evidence of his suffering by the 
distressed expression of his face, especially if a cough cause any sudden 
movement of the side. There is also tenderness of the chest-wall over the 
seat of disease, for pressure is evidently painful. In addition to the above 
symptoms there is generally headache ; the tongue is furred ; there may be 
vomiting, and for the first few days there is always fever, even in cases 



446 DISEASE IIS" CHILDREN. 

where the temperature is afterwards normal. The pulse is quickened, and 
the respirations are more hurried than natural ; but they are not, as is 
the case with pneumonia, increased out of proportion to the pulse. Conse- 
quently, there is little or no perversion of the pulse-respiration ratio. The 
cough does not usually begin until an appreciable interval has passed from 
the onset of the illness. Often, for the first twenty-four or forty-eight 
hours, little cough is noticed. When it comes on it is hard and dry, and 
the increased movement of the chest-walls by which it is accompanied is a 
cause of much suffering. The strength of the child fails comparatively 
little. There is by no means the marked muscular prostration which is so 
noticeable a feature in pneumonia. On the contrary, if the pain be not 
severe, the child seldom takes voluntarily to his bed, but will walk about 
as usual without any pronounced sense of fatigue. If the pain is severe, 
he is quiet and indisposed to exert himself ; but this inclination to rest is 
the consequence of pain, which is increased by movement, and is not due 
to any sense of muscular weakness. 

The degree of fever varies. Usually for the first few days the tem- 
perature rises to 102° or 103° in the evening, falling to 99° or 100° in the 
morning. After the first week the fever may either persist, or the temper- 
ature may fall gradually to the normal level. In a child of perfectly 
healthy constitution, if the pleurisy be primary and uncomplicated, the 
fever usually is moderate and quickly subsides. Persistent high tempera- 
ture in a case in which the pleurisy is primary and uncomplicated is usually 
a sign that the patient is of strumous constitution. 

It is not in every case that the onset of the disease is so marked as de- 
scribed above. The illness often begins insidiously and is only discovered 
by the pallor of the child, and the shortness of his breath on any exertion. 
The latent form of the disease is especially common in infants, particularly 
if the child is suffering at the time of the attack from any wasting disease. 
In these cases there is often no fever, or only a trifling rise of temperature ; 
there may be no cough ; and attention may only be directed to the chest 
by noticing that the child is breathing quickly and has less appetite than 
usual for his food. 

The pain of pleurisy is usually only severe at the beginning of the ill- 
ness, and often subsides as effusion takes place into the pleura. This is 
not, however, always the case. Sometimes it continues with extreme ten- 
derness of the affected side until towards the close of the disease. Unless 
the tenderness be great, the child usually lies on the affected side for the 
sake of giving increased freedom to the healthy lung, which has to do 
double duty as a respiratory organ. If the tenderness is marked, the pa- 
tient lies on his back. It is not often that he is seen resting on the sound 
side. 

If the disease continues for two or three weeks, the fluid usually becomes 
purulent. There are, unfortunately, no positive symptoms which indicate 
that the effusion is no longer serous. Even the time which has elapsed 
from the beginning of the illness is no positive guide, for in some children 
the fluid becomes purulent much more quickly than it does in others ; and 
in exceptional cases it may be purulent from the first. The tint of the 
face is, however, often a suspicious symptom. For many years I have been 
accustomed to note the colour of the face in children the subjects of pleu- 
risy. In many it assumes a peculiar straw-yellow hue which is unlike the 
complexion of any other disease. This symptom is rarely seen during 
the first week of the illness, and seldom attracts the eye before the end of 
the second week. If well defined, it is often coexistent with purulent 



PLEUEISY — SYMPTOMS. 447 

change in the contents of the pleural cavity. Still, I have seen it well marked 
in a case where the fluid withdrawn by the aspirator was perfectly clear. A 
boy in the East London Children's Hospital, aged six years, was noticed to 
have a most marked straw-yellow tint of the face and neck. The left side 
of the chest was full of fluid, which had pushed his heart into the epigas- 
trium. With the aspirator, nineteen ounces of clear pale yellow fluid were 
withdrawn. 

When the fluid has become purulent (empyema) the child usually wastes • 
but great differences are observed in the extent to which nutrition suffers 
even in these cases. Much, probably, depends upon the temperature, as 
this may be taken to indicate with fair accuracy the degree to which the 
system is fretted by the purulent contents of the thorax. If there be much 
fever, wasting is rapid. The child has a distressed expression and becomes 
profoundly anaemic ; his strength diminishes ; the straw tint of the face 
may spread more or less over the whole body ; the skin becomes dry and 
harsh, and the fingers get clubbed at the extremities. In very rare cases 
a trace of oedema may be detected in the legs without albuminuria ; but I 
have known this symptom to occur only in one instance, and in this albumi- 
nuria followed after a few weeks. Empyema in scrofulous subjects is al- 
most invariably accompanied by fever. The temperature rises to 102° or 
103° at night, sinking in the morning to the natural level. In children of 
healthy constitution the presence or absence of fever appears to depend in 
a great measure upon the natural nervous excitability of the child and his 
tendency to respond readily to any source of irritation. In many children 
with a chest more than half full of purulent fluid the temperature is nor- 
mal and the nutrition fairly good ; and although signs of anaemia may be 
noticed, the strength and spirits are not greatly depressed. 

The physical signs in cases of pleurisy in the child must be studied with 
attention, for they often resemble those of croupous pneumonia very closely. 
On account of the weakness of vocal fremitus in early life no assistance is 
to be obtained from the presence or absence of vibration of the chest-wall 
— a sign which in the adult is of extreme value in the detection of fluid. 
The auscultatory signs, also, may present so close a similarity to those of 
inflammation of the lung that, in themselves, without reference to the situa- 
tion in which they occur, they are not distinctive of pleurisy. Indeed, in 
many cases it is only by a comparison of the physical signs with the general 
symptoms of the disease that we can arrive at an accurate conclusion as to 
the nature of the illness. 

On inspection of the chest-wall we can often detect a certain impairment 
of movement on the affected side ; but the intercostal spaces are not 
necessarily bulged and motionless even in cases where the amount of fluid 
is large. In young children, whose respiration is principally diaphragmatic, 
the walls of the chest move comparatively little in inspiration ; and the 
closest inspection can often discover no difference in this respect between 
the two sides. Although the intercostal spaces may move as in health, the 
whole of the affected side is fuller than the other. It may not, indeed, as 
has been pointed out by Dr. Gee, show any difference to the measuring 
tape ; but the outline, as taken with the cyrtometer, is much squarer than 
natural from a bulging at the antero-lateral angle of the chest-wall. If the 
amount of effusion is more than moderate, the neighbouring organs are 
displaced by pressure of the fluid. The liver and spleen can be felt more 
distinctly than in the normal state, and the heart's apex is pushed to one 
side. In cases of right-sided pleurisy the apex is displaced to the left, and 
can be felt beating outside the nipple line. If the effusion occupy the left 



448 DISEASE IN CHILDREN. 

side, the cardiac impulse may be felt near the ensiform cartilage. These 
signs, especially the latter, according to my experience, are as well marked 
in the child as in the adult, and should be always looked for. Displace- 
ment of the heart to the right is sometimes prevented by adhesions formed 
between the pericardium and the left pleura. Sometimes an alteration in 
the size of the heart may prevent the displacement of the organ from being 
noticed. Thus, if the left ventricle is much hypertrophied, the apex-beat 
under ordinary circumstances is felt to the left of the nipple line. In such a 
case displacement of the heart to the right by fluid in the left pleura may 
do no more than restore the apex-beat to the normal position. A little 
girl, aged nine years, with old-standing heart disease and hypertrophy of 
the left ventricle, was admitted into the hospital with considerable pleuritic 
effusion of the left side. The heart's apex. was felt beating behind the 
sixth rib in the left nipple line. After absorption of the fluid the cardiac 
apex had moved one inch to the outer side of the nipple line. 

Palpation of the affected side does not always discover obliteration of 
the intercostal depressions, although sometimes it will do so. Often, es- 
pecially in cases where there is little thickness of lymph lining the pleura, 
a tap with the finger between two of the ribs will be readily transmitted 
through the fluid to a second finger resting upon a distant part of the 
same interspace. Vocal vibration of the chest-wall is, as a rule, completely 
absent in the healthy child. Sometimes, however, if strong on the sound 
side, it may be conducted by the chest-wall to the other half of the chest, 
and be felt distinctly over the whole of the affected side. I have known 
this phenomenon to be present in a case where ten ounces of fluid were 
removed by paracentesis. Immediately before the operation the vocal 
vibration was little less strong than on the sound side. On account of 
its frequent absence, and uncertain value when present, vocal fremitus is 
not to be depended upon in the } T oung subject. If, however, we can feel a 
distinct fremitus over the sound lung, its absence over the affected side of 
the chest is important ; but this is exceptional. 

On percussion of the affected side there is complete dulness with greatly 
increased sense of resistance. These are very important signs. In no form of 
pulmonary consolidation — except, perhaps, in extensive fibroid induration 
of the lung with secondary pneumonia — is such a dull, flat note, with so 
marked a sense of resistance to the finger, to be found. The impression to 
the ear and the touch is exactly that derived from percussing a thick block 
of wood. The dead, flat note is not, however, to be obtained all over the 
affected side of the chest. In the upper intercostal spaces in front, and 
along the side of the spine behind, a tubular (tympanitic) note is often 
elicited, due to the presence of under-lying relaxed lung-tissue ; and in the 
infra-axillary region it is common to find a well-marked resonance, owing to 
the transmission of the stomach note through the lower part of the fluid. 
This pseudo-resonance is often a source of perplexity ; but we usually find 
that on employing very gentle percussion in this region the note is dull, 
while a sharper stroke in the same spot produces a loud resonance such as 
was heard at first. It is very important not to be misled by this source of 
confusion, for one of the distinctive marks of fluid in the pleura lies in the 
general distribution of the dull percussion note on the affected side. In 
ordinary cases of pleurisy the dulness extends all round the side of the 
chest, both behind and in front, although the upper limit of the dulness 
rises to a higher level at the back than it does anteriorly. 

Besides the general distribution of the dulness, the alteration of the 
percussion note on change of position is a valuable sign of fluid in the chest. 



PLETTEISY — SYMPTOMS. 449 

If the amount of fluid is moderate, and is not confined within narrow limits 
by adhesions, it tends to gravitate to the most depending part, so that the 
side of the chest which is turned uppermost gives a clear note to the per- 
cussing finger. This sign is almost invariably present during the stage of 
absorption. 

The auscultatory signs of pleurisy in the child are often very peculiar. 
Sometimes, as in the adult, we find weak, almost suppressed, breathing over 
the area of dulness, with an occasional graze or scrape of friction above the 
upper border of the effusion. Often, however, the signs are much less 
characteristic. It is not uncommon to find a loud blowing, tubular, or even 
cavernous breath-sound over the scapula behind and in the axillary region. 
Sometimes this is heard almost as far as the base, and usually it can be de- 
tected below the level of the effused fluid. This character of the respira- 
tory sound is not confined to cases where the lung is consolidated from 
pneumonia, for it is often present when the temperature is normal. The 
vocal resonance may be exaggerated, and about the lower angle of the 
scapula is frequently bronchophonic. Often it has a pronounced ?ego- 
phonic quality. The bronchophonic character is not, however, always 
found in places where the breathing is bronchial or blowing. Over a spot 
where the respiration is typically tubular, vocal resonance may be com- 
pletely suppressed. 

The characters of the friction-sound in children are also peculiar. It 
is exceptional to hear the common rub or scrape which is so familiar a 
sign in the adult patient. In the child the friction-sound has often a 
crackling or crepitating character, which to the inexperienced ear is 
suggestive rather of intra- than of extra-pulmonary mechanism. It has 
not, however, the puffy character of pneumonic crepitation ; and is very 
superficial sounding, as if generated close to the ear. Often, from the 
character of the sound alone, it is difficult to say whether it is produced in 
the lung or in the pleura, especially as a large, hard, bubbling rhonchus is 
sometimes heard, which is evidently of intra-pulmonary mechanism and is 
due to catarrh of the air-tubes. This disappears after a cough. 

The friction is not limited to spots in the pleura above the level of the 
fluid. In pleurisy, as in pericarditis, effusion does not necessarily suppress 
friction. It is not uncommon to hear an unmistakable friction-sound at a 
spot where immediately afterwards the aspirating needle withdraws several 
ounces of fluid. 

In cases where the effusion is very copious the symptoms may be dis- 
tressing, and the child's life be placed in the greatest danger. This is espe- 
cially the case when the fluid occupies the left side of the chest. In this 
situation it may push the heart so far to the right that the apex is felt 
beating under the right nipple. Consequently, the large vessels may be 
bent out of their natural course, and great obstruction to the circulation 
may result from the interference with their calibre. The healthy lung, 
hampered in its functions, may become engorged, and the difficulty in 
the return of blood to the heart may produce great congestion of the 
head, face, and extremities. The child is seen sitting up, gasping for 
breath, with an agonized expression on his dusky face. His eyes are star- 
ing and congested ; his hands and feet are purple ; his skin is cold and 
bathed in sweat ; the veins of the neck are swollen ; his pulse is small, 
feeble, and frequent ; and unless the distress be quickly relieved death is 
certain. 

Terminations. — In cases where the fluid remains serous, it usually be- 
comes rapidly absorbed. The general symptoms are slight and quickly 
29 



450 DISEASE IN CHILDEEN. 

subside, and the physical signs return to a state of health. In these 
cases dulness on percussion and weak breathing can be detected longer in 
the infra-axillary region than elsewhere. If absorption of the fluid be 
slow, some retraction of the side is often observed for a time ; but in such 
cases it is usually slight, and is seldom noticed to the degree which is so 
common after removal of a purulent fluid from the chest. If absorption 
is complete, the deformity soon passes away and the chest recovers its 
symmetry. 

When the fluid has become purulent, absorption goes on very slowly. 
It is only when the quantity is very small that anything approaching to 
completeness of absorption is found. It is in cases of empyema that 
distortion of the chest is commonly noticed. The spine becomes curved 
with the concavity towards the diseased side ; the shoulder, nipple, and 
inferior angle of the scapula sink, and the lower part of the shoulder- 
blade projects backwards from the chest-wall. Such retraction of the af- 
fected side takes place before absorption has ceased. Indeed, as Dr. T. 
Barlow has very justly pointed out, the fact that retraction of the side has 
occurred is by no means a positive proof that absorption has been com- 
pleted. On the contrary, if the deformity continues without improvement, 
it rather tends to suggest the possibility of some unabsorbed purulent 
matter remaining at the base of the lung or between the lobes. In many 
of these cases a layer of cheesy matter is left coating the base of the lung ; 
and a quantity of thick creamy pus is often found on dissection collected 
in a limited abscess on the surface of the diaphragm. 

If the amount of purulent fluid is large, it sooner or later, unless with- 
drawn by the aspirator, points at some part of the chest-wall. If this oc- 
cur in an upper intercostal space, the contained fluid cannot be completely 
evacuated, and a continuous discharge occurs through the opening. The 
child grows daily weaker and thinner. His breath is short ; his face gets 
sallow and often earthy in tint, with livid ity about the eyes and mouth ; 
his fingers become clubbed ; his digestion is impaired, his tongue foul, 
and his breath offensive ; the liver and spleen become enlarged from al- 
buminoid degeneration ; the cough is spasmodic and painful ; and the 
child sinks and dies from asthenia. Death may be preceded by profuse 
diarrhoea, which, sometimes at least, is due to albuminoid change in the 
coats of the bowel. 

If the abscess point in a lower intercostal space, so that the chest 
cavity can be completely drained, recovery may occur without operative 
interference. I have met with at least one such case where, although 
there was at first some deformity of the affected side, this entirely disap- 
peared ; but it must be confessed that such a fortunate result is not com- 
mon. 

Sometimes the purulent fluid, instead of discharging itself through the 
chest-wall, perforates a bronchus and is coughed up through the lung. 
Large quantities of purulent matter may be thus expectorated, but con- 
trary to what might be supposed, no air enters the pleural cavity and the 
physical signs are not found to have undergone any special alteration. 
Indeed, if the case terminate fatally, it is very rare to find on the closest 
examination any direct communication between the lung and the chest 
cavity. Spontaneous evacuation through the lung is not confined to cases 
where no operative procedure has been attempted. It may also occur 
after a part of the contained fluid has been removed by paracentesis. This 
mode of ending is often followed by complete recovery. If the pleural 
cavity can be thoroughly evacuated by this means, and the lung is not 



PLETJEISY — TERMINATIONS — VARIETIES. 451 

bound clown beyond possibility of expansion, recovery may take place with- 
out any permanent retraction of the affected side. 

A little boy, aged five years, was brought into the East London Chil- 
dren's Hospital for an empyema of six weeks' standing. The effusion occu- 
pied the right side and appeared to be copious, for the intercostal spaces 
were obliterated and the heart's apex was felt beating to the outer side of 
the left nipple line. On percussion, dulness was complete over the whole 
of the right side, both back and front ; there was marked sense of resist- 
ance ; and the breath- sounds, although blowing in quality, were excessively 
weak. The temperature was normal. 

A few days after the boy's admission eleven ounces of thick, greenish, 
inodorous pus were withdrawn by the aspirator. After the operation the 
dulness and weak blowing breathing remained the same, but the intercostal 
spaces had become visible, and the heart's apex had returned as far as the 
nipple line. A week afterwards the boy coughed up twelve ounces of thick 
pus, and in a few days a further four ounces. After this the percussion 
note was decidedly less dull ; the resistance was diminished ; and the breath- 
ing was loud and tubular over the whole of the upper half of that side, 
cavernous below. Vocal resonance was loud and segophonic. 

For some weeks the boy continued to spit up several ounces of puru- 
lent matter every few days ; and in the end made a perfect recovery with- 
out any contraction of the chest-wall. The temperature was normal as a 
rule ; although sometimes it would suddenly rise to 103° or 104°, but never 
remained elevated more than a few hours. These elevations did not cor- 
respond with or precede the passage of pus through the lung. A year 
afterwards the boy was readmitted with acute pleurisy of the opposite side 
(the left) ; and this attack also was perfectly recovered from. 

In many cases of perforation of a bronchus there is the same difficulty 
in completely evacuating the pleural cavity as is found when the discharge 
takes place through the chest-wall. Sometimes the opening into the bron- 
chus closes, and pus ceases to be expectorated. Retention of purulent 
matter then occurs, and the chest may become much distorted, or the 
child, after a lingering illness, may die of asthenia. 

Even when the operation of paracentesis is performed and the puru- 
lent fluid is removed artificially, the case is by no means necessarily at an end. 
Sometimes, after withdrawal of as much fluid as can be made to pass through 
the aspirator, no further accumulation occurs ; absorption of what remains 
in the pleural cavity goes on uninterruptedly, and the child is soon well. 
These cases are, however, exceptional. It is often necessary to repeat the 
operation several times, and not unfrequently, as the purulent fluid con- 
tinually reaccumulates, other measures have to be adopted as will be after- 
wards described. In prolonged cases, whether a fistula be present in the 
chest-wall or not, secondary tuberculosis is liable to occur ; and it is not 
very uncommon to find great enlargement of the liver and spleen from 
amyloid degeneration. 

Another occasional consequence of long-standing pleurisy is a fibroid 
change at the base of the lung leading to induration of the tissues and di- 
latation of bronchi. This subject is elsewhere referred to (see Fibroid In- 
duration). 

Varieties. — Certain varieties of the disease are commonly met with. In 
some cases the lymph exudation is unaccompanied by liquid effusion (plas- 
tic or dry pleurisy). In others, the inflammation, instead of being general 
over the whole side, is confined within certain limits (localised or loculated 
pleurisy). In others, again, the disease may attack the two sides simulta- 



452 DISEASE IN CHILDREN". 

neously. Double pleurisy is often in the child the consequence of tuber- 
culosis. 

Plastic Pleurisy, although sometimes primary, is for the most part in 
young subjects secondary to some other disease. It is common in cases of 
phthisis, and sometimes occurs in the course of catarrhal pneumonia. Dry 
or plastic pleurisy is often overlooked, as it may give rise to but few symp- 
toms, or to symptoms so slight that they are masked by the other more 
prominent manifestations of the disease in the course of which they have 
arisen. This form is of little importance. It is usually accompanied by 
some pain in the side and a teasing cough. On examination of the chest, 
dulness is discovered at the seat of pain, and a little crepitating friction or 
a superficial rub can be heard with the stethoscope. The inflammation 
leads to adhesion between the opposed surfaces of the pleura. 

Loculated Pleurisy is very common in children. The inflammation may 
occupy any part of the serous surface. It may be limited to the membrane 
covering the diaphragm or to that surrounding the base of the lung ; it may 
be seated at the upper part of the pleural cavity, such as the infra-clavicu- 
lar region ; or it may occupy the space between the lobes. In many cases 
the localisation of the disease is due to old adhesions resulting from a pre- 
vious attack, so that the fluid thrown out is prevented from gravitating 
downwards or spreading over the general cavity of the pleura ; but in 
others no history of a similar illness can be discovered. 

In ordinary cases of loculated pleurisy the general symptoms do not 
differ from those met with in the more common form of the disease. But 
the physical signs are more characteristic. Over the collection of fluid the 
percussion-note is completely dull, with great sense of resistance ; the res- 
piration is weak, and may be of bronchial, blowing, or cavernous quality ; 
there is seldom any friction-sound to be heard, and the vocal resonance is 
ordinarily suppressed. Such signs may be discovered over the whole front 
of the chest ; they may be limited to the infra-clavicular or infra-mammary 
regions ; they may be found in the scapular region behind, or at the lower 
part of the axillary region at the side. The most difficult to detect of these 
partial pleurisies is no doubt that variety in which the inflammation and 
effusion are confined to an interlobar space. In such a case there may 
be considerable retraction of the side from compression of the lung ; or the 
physical signs may occupy so limited an area as to escape recognition, and 
there may be no displacement of the heart. After the fluid has become 
purulent, the cough, the wasting, and the cachectic appearance of the child, 
coupled with the insignificant character of the physical signs, often suggest 
tuberculosis. 

Diaphragmatic pleurisy is rare in the child. The disease begins sud- 
denly with a severe pain shooting across the chest and great oppression of 
breathing. The child sits up in bed with a distressed face. His skin is 
hot, and every attempt to draw a deep breath is a cause of great suffering. 
The physical signs are often very indefinite ; but usually some dulness 
may be discovered at the extreme base on one side, with weak breathing ; 
and often after a day or two the ordinary signs of pleurisy can be detected 
at the lower part of the same side ; for diaphragmatic pleurisy rarely re- 
mains limited to the diaphragm in early life. 

Tuberculous Pleurisy. — AVhen pleurisy occurs as a consequence of 
tuberculosis it is usually double ; but every case of double pleurisy in 
the child is not necessarily tuberculous. Nor, again, in every case of 
pleurisy in a tuberculous subject is the serous inflammation always secon- 
dary to the diathetic disease. It has been already stated that tuberculosis 



PLEURISY— VARIETIES— DIAGNOSIS. 453 

is a common sequel of empyema of long standing ; and a purulent collec- 
tion in the chest precedes tuberculosis much more often than it follows it. 
In cases where pleurisy is met with as a secondary disease the inflamma- 
tion is usually of the plastic variety ; although sometimes there is also 
serous or purulent effusion in the chest-cavity. We can only say positively 
that tuberculosis is the primary disease when the symptoms of the con- 
stitutional malady — wasting, moderate fever, loss of colour and strength, 
a distressed expression of face and occasional cough — have preceded by a 
definite interval the local signs of serous inflammation. 

When tuberculosis follows empyema the temperature, if it had subsided, 
rises to between 101° and 102° or higher every evening, falling again to 
between 99° and 100° in the morning. The child loses flesh, colour, and 
strength more rapidly than the condition of his chest is sufficient to ex- 
plain. His face is haggard and careworn ; his skin harsh and dry ; often 
diarrhoea comes on ; sometimes he vomits ; his belly swells ; and an attack 
of basic meningitis usually brings the illness rapidly to a close. 

Complications. — Besides tuberculosis and amyloid disease of organs 
(which have been already alluded to), there are other complications which 
may be present in cases of pleurisy. Pericarditis is not uncommon as an 
accompaniment of the pleural inflammation. This subject is referred to 
elsewhere (see page 158). Moreover, serous inflammation in the chest some- 
times spreads upwards from the peritoneum. More often, however, it pen- 
etrates downwards through the diaphragm to the abdominal cavity. It is 
then usually fatal (see page 685). 

Diagnosis. — On account of the resemblance of its physical signs to those 
of pneumonia, pleurisy is often mistaken for that disease. The difficulty 
in making the distinction is due principally to the absence of vocal fremitus 
in the child ; to the occasional loud blowing or tubular breathing which is 
often heard over the seat of dulness ; and to the crackling character of the 
friction, which suggests rather an intra-pulmonary crepitation than a 
pleural rub. In order to distinguish between the two diseases we must 
take into account the mode of invasion, the nature of the symptoms, and 
the character of the physical signs ; for in all these points great differences 
are to be observed. 

The occurrence of pain in the side and fever, followed after an interval 
by cough, is characteristic of pleurisy. In pneumonia cough is usually 
present from the beginning, and pain in the side, unless pleurisy accom- 
pany the inflammation of the lung, is moderate or absent The after 
symptoms also are different. In pleurisy the cough is dry and painful ; 
the pulse-respiration ratio is unaltered ; the face is pale or congested at 
first, afterwards straw yellow ; and there is little loss of muscular strength. 
In pneumonia the cough occurs in short hacks, accompanied in the older 
children by the expectoration of rusty sputum ; the pulse-respiration ratio 
is perverted ; the face has a bright flush on the cheeks ; and muscular 
prostration is a marked feature. The physical signs also are distinctive. 
In pleurisy the chest, even if not enlarged to the measuring tape, is square 
in outline ; the heart's apex is displaced ; the dulness is complete, the note 
being perfectly flat, and the sense of resistance to the finger extreme ; the 
respiratory sounds, although they may be as tubular as in a case of typical 
pulmonary inflammation, are always less loud at the base than above ; and 
the crackling friction has not the "puffy" character of pneumonic crepita- 
tion. The chief difference, however, consists in the fact that in an ordinary 
case of pleurisy the abnormal physical signs are found both at the back 
and front of the affected side. In pneumonia there is no displacement of 



454 DISEASE IN CHILDREN. 

the heart's apex ; the dulness is not complete ; the sense of resistance, 
although greater than natural, is only moderately increased ; the resonance 
of the voice at the angle of the scapula is never segophonic ; and the 
physical signs, unless the inflammation occupy the apex of the lung, are 
limited to the anterior or posterior aspect of the chest, and are only in 
very extreme cases found over the whole of the affected side. 

Between an ordinary case of pleuritic effusion and an ordinary case of 
lobar inflammation of the lung the differences are so great, that there is 
little difficulty in making the distinction. But to decide between a local- 
ised pleurisy and a case of lobar pneumonia is not so easy. Still, even 
here, by attention to the mode of invasion and the character of the symp- 
toms, and by remarking that, although limited to one aspect or one region 
of the chest, the percussion-note is completely toneless, the sense of re- 
sistance is extreme, and the weak breath-sound is not accompanied by cre- 
pitation at the borders of the dull area (for, in localised pleurisy friction is 
rarely to be heard), we can usually come to a satisfactory conclusion. The 
very fact of these physical signs continuing for a considerable time un- 
changed is in itself a strong argument in favour of the pleuritic nature of 
the complaint. Dr. Wilks, indeed, lays it down as a rule that local dul- 
ness with distant tubular breathing, or absence of breath-sound, persist- 
ing after an inflammatory attack in the chest, indicates the presence of a lo- 
cal empyema ; and if no adventitious sounds accompany the respiration, we 
may, no doubt, commit ourselves to this diagnosis without hesitation. 

Ordinary cases of catarrhal pneumonia, where the inflammation occu- 
pies both lungs, cen rarely resemble pleurisy closely enough to be con- 
founded with it. Unless the catarrhal pneumonia be accompanied by plastic 
pleurisy, the percussion-note is only moderately dull ; the resistance is little 
increased ; there is usually loud tubular or cavernous breathing at the ex- 
treme base from dilatation of the bronchi ; and the profuse crepitation has 
a crisp metallic quality which bears little resemblance to the sound pro- 
duced in an inflamed pleura. It is in cases where the catarrhal inflamma- 
tion occurs secondarily in a lung which is already the seat of fibroid indura- 
tion that a real difficulty is found. Here the inflammation is confined to 
one lung and spreads rapidly, so as to involve the whole thickness of the 
organ. Consequently, the lung, already indurated by the fibroid change, 
gives a character to the percussion-note which is indistinguishable from 
that produced by pleuritic effusion ; and we find a complete, toneless dul- 
ness with marked sense of resistance all round the affected side — both at 
the back and front. In the indurated lung, however, the tubular or cav- 
ernous breath-sound is accompanied by a large metallic bubbling rhonchus. 
In pleurisy the breathing is usually accompanied by no adventitious sound ; 
but if a little crepitating friction be present, it is much drier in character, 
and has not the loud ringing resonance which is given to a rhonchus gene- 
rated in a rigid dilated air-tube. In both the vocal resonance may be 
bronchophonic, but in pneumonia it never has an aegophonic quality. 

Collapse of the lung in exceptional cases may present a very close re- 
semblance to pleurisy ; but the dulness on percussion is rarely so complete, 
and the sense of resistance seldom so great in collapse as in fluid effusion. 
The resistance in the latter case to the percussing finger is an element of 
the utmost importance in the diagnosis, and is only equalled in point of 
intensity by a fibroid induration of the lung with superadded catarrhal 
pneumonia, as already described. 

With regard to the varieties of pleuris} r , it is often very difficult to say 
whether the fluid is serous or purulent, or, indeed, whether the physical 



PLETTKISY — DIAGNOSIS— PROGNOSIS. 455 

signs are not due to a coating of lymph without liquid effusion at all. If 
a change in the percussion-note and the character of the physical signs 
follows a change in the position of the patient, the presence of fluid is 
placed beyond the possibility of doubt. But if no such characteristic sign 
of fluid can be discovered, it is no proof that fluid is not present. The 
effusion may be kept in place by adhesions, or there may be sufficient lymph 
coating the pleura to produce a dull percussion-note, although fluid be no 
longer in contact with the wall of the chest at the point of examination. 
An segophonic resonance of the voice is a certain sign of effusion ; but its 
absence is by itself no sufficient proof of the absence of fluid. If, however, 
the outline of the affected side be elliptical and the heart's apex in the 
natural position ; if the intercostal spaces sink in normally, the percussion- 
note be dull in all changes of position, the respiration be weak over the 
affected side without blowing quality, and the vocal resonance not at all 
aagophonic, it is almost certain that no fluid is present. Even here, how- 
ever, no positive conclusion can be arrived at, for with such signs there may 
be an encysted collection of pus at almost any part of the chest. 

The distinction between a serous and a purulent effusion is very diffi- 
cult. No information can be gained from the temperature, for this may be 
elevated or not without reference to the character of the fluid. It is often 
high with a serous effusion and perfectly normal with a large purulent 
collection in the chest. Again, the physical signs are the same whatever 
be the nature of the pleural contents ; for Bacelli's sign (i.e., the clear and 
articulate conduction of the whispered voice to the chest-wall as indicative 
of serous and exclusive of purulent effusion) has not unfortunately the 
value attributed to it by this physician. The tint of the face, however, if 
the complexion have assumed the straw yellow hue, although not a decisive 
proof, is very suggestive of empyema ; and marked clubbing of the finger- 
ends, according to Dr. T. Barlow, is never the consequence of serous effu- 
sion. In every case of doubt an exploratory puncture 1 with the hypoder- 
mic injection syringe, by withdrawing a specimen of the fluid, will at once 
decide the question. 

Hydro thorax is as a rule readily distinguished from pleurisy by noting 
the evidences which are always present of interference with the general cir- 
culation. Dropsy of the pleura is almost always a part of general anasarca. 
There is disease of the heart or kidneys ; the effusion occurs on both sides 
simultaneously ; and there is also ascites or more or less general oedema. 

Prognosis. — In cases of pleurisy the prognosis depends in a great meas- 
ure upon the age and constitution of the child. Under the age of six months 
the disease is a very serious one, and often ends in death. After that early 
period the prognosis is good, as a rule, if the child be not the subject of a 
diathetic taint. The scrofulous habit is, however, a distinctly unfavourable 
element, for although the disease may eventually end happily, the fluid 
tends to become quickly purulent ; the febrile excitement is usually great ; 
interference with nutrition is marked ; and not unfrequently the fluid is 
continually reproduced as often as it is evacuated. 

If the fluid remain serous, recovery is certain unless the fluid accumu- 
late to such a degree as to dislocate the heart and interfere with the passage 
of the blood through the large vessels. In such cases death may occur un- 
less the child be rapidly relieved by operation. When the fluid has become 

1 It may be observed, with regard to making exploratory punctures, that the operation 
is less painful if a spot be selected where the skin is thin, as in the axilla, than if the 

where the cutis is thick and resistant. 



456 DISEASE m CHILDREN. 

purulent the prospect is more serious, but less so in childhood than in 
after years ; for if proper measures be adopted a large majority of these 
cases recover. A high temperature is an unfavourable sigD, and the con- 
tinuance of the pyrexia after discharge of the purulent matter by operation 
should occasion great anxiety. Still, even in these cases recovery often 
follows. Again, the sudden sinking of the temperature to a point below 
the level of health is, as Wunderlich has pointed out, a sign of unfavour- 
able import. 

If the empyema burst spontaneously through the chest-wall, recovery 
rarely takes place unless the opening be seated in a lower intercostal 
space, or unless an artificial opening be established in a more suitable 
position. Spontaneous cure is more likely to follow evacuation through a 
bronchus ; and a large proportion of these cases get well. Still, if the cir- 
cumstances are such that retention of purulent matter takes place, the 
child, if left alone, may sink exhausted. 

Fetor of the pus is a bad sign. Unless prompt antiseptic measures are 
adopted, these cases always end fatally. 

Secondary pleurisy is much more dangerous than the primary form of 
the disease. The fluid is more likely to become purulent at an early date ; 
and the child, already weakened by his first illness, is in an unfavourable 
condition to support the exhausting influence of a chronic empyema upon 
his nutrition. 

Treatment. — A child attacked by acute pleurisy should be at once put 
to bed, for absolute rest is of the highest importance. A febrifuge mix- 
ture should be ordered, and the diet should consist of milk and broth. 
If the pain in the side be severe, a leech or two may be applied if the child 
is robust ; or a hypodermic injection may be given containing one-twelfth 
of a grain of morphia for a child of four years of age. A firm bandage 
round the chest is often successful in giving great relief ; and a thick layer of 
wadding around the affected side is useful for the sake of warmth. Some 
physicians advocate a careful strapping of the chest over the affected lung 
with broad strips of adhesive plaster. I have made use of this plan, but 
cannot say I have noticed any distinct advantage from its employment. In 
diaphragmatic pleurisy where the pain is severe, a firmly applied bandage 
to the abdomen, so as to limit the action of the diaphragm, often affords 
ease. The bowels, if confined, must be relieved by mild aperients, such 
as the liquid extract of rhamnus frangula or the compound liquorice 
powder ; but violent purgation is hurtful and should be avoided. Mer- 
cury, the favourite remedy in former days, is now seldom recommended. 
Still, in some cases, one grain of gray powder given twice a day, with an 
equal quantity of quinine, or with five grains of the peroxide of iron, has 
sometimes seemed to me to be beneficial. Iodide of potassium is, however, 
usually to be preferred, and this salt, given in full doses, I believe to be of 
distinct advantage to the patient. I am in the habit of ordering for a 
child of four years old, five, eight, or ten grains of the iodide, to be taken 
every six hours, and look upon the remedy given in such doses as a valu- 
able promoter of absorption. The internal remedy should be always sup- 
plemented by counter-irritation of the chest-wall. Directly the tempera- 
ture falls, or earlier if effusion appears to have ceased, the liniment or 
tincture of iodine (according to the sensitiveness of the skin) should be 
painted over a limited surface every night. This application is most use- 
ful if applied over an area of two or three inches in diameter — repainting 
the same on each occasion. When the skin begins to look dry and cracked, 
another spot is selected, and the process is repeated regularly as before. 



PLEUKISY— TKEATMENT. 457 

If, after a week, the fluid remains stationary, without sign of absorp- 
tion it is better to change from the iodide to a chalybeate, or to add five 
or six grains of the tartrate of iron to the mixture. In scrofulous children, 
when effusion has ceased, it is advisable to improve the diet ; and pounded 
meat, strong meat broths, yolks of eggs, and moderate quantities of stim- 
ulant are usually required. 

If at the end of a fortnight the effusion has been unchanged in amount, 
it is probably purulent. An exploratory puncture should be made with a 
fine needle syringe, and if pus be withdrawn, measures should at once be 
taken to evacuate the chest. If the fluid is found to be serous it is ad- 
visable to wait for a few days, for this small operation and the abstraction 
of even the limited quantity withdrawn by the test puncture, may act as a 
stimulus to absorption and be followed by the rapid removal of the fluid 
by natural means. At the same time the quantity of liquid taken by 
the child should be restricted ; for a dry diet in such cases by stinting 
the blood of fluid often greatly promotes the action of the absorbent 
vessels. 

Often when effusion is undoubtedly present the introduction of the 
exploring needle is followed by no appearance of fluid ; or although pus 
has been withdrawn by the test puncture the aspirator needle is intro- 
duced without any result. The instrument may have entered the chest- 
cavity at a spot where the lung is adherent to the parietes, or the layer 
of false membrane lining the pleura may be so thick that the needle 
fails to penetrate into the sac. In choosing a place for the puncture 
it is advisable to select one where the dulness is complete ; and it is 
well, as Dr. Allbutt has suggested, to look for a spot where there is 
bulging of the intercostal space, as here the false membranes are scanty 
and thin. Often it is necessary to puncture several times, on each oc- 
casion selecting a fresh spot, before we succeed in obtaining evidence of 
fluid. 

In some cases the difficulty met with in withdrawing the fluid is due to 
rigidity of the chest-walls. If the walls of the empyema cavity cannot 
collapse, there is no expolsive force to drive out the fluid. As Mr. E. W. 
Parker has pointed out, the pleural cavity is emptied by the pressure of 
the atmosphere acting in three different ways. It acts on the condensed 
lung causing it to re-expand, on -the diaphragm causing it to ascend, and 
on the thoracic wall causing it to fall in. If for any reason pressure can- 
not be brought to bear on the confined fluid, no amount of suction force 
will have any power of withdrawing the liquid contents of the chest. In 
not a few cases, the aspirator being found to be useless and no fluid ap- 
pearing after repeated punctures, we are forced to incise the chest and 
insert a drainage-tube in order to evacuate the pleural cavity. Mr. Parker 
has devised an apparatus to meet this difficulty, by means of which filtered, 
warmed, and carbolised air can be pumped into the upper part of the chest 
while fluid passes out through the aspirator needle introduced into the 
lower part. 

The above are not the only causes by which thoracentesis is rendered 
difficult. Large thick flakes of lymph may be present and obstruct the 
opening of the needle or drainage-tube. A child, aged one year and eight 
months, was admitted under my care into the East London Children's 
Hospital, with the physical signs of a large effusion on the left side of the 
chest. An exploratory puncture showed pus to be present. Many attempts 
were made to aspirate the chest, but only small quantities of pus could be 
withdrawn. After repeated failures it was determined, in consultation with 



458 DISEASE IN CHILDREN. 

my colleague Mr. Parker, to incise the wall and put in a drainage-tube. 
This was done, but even then pus did not flow freely. Mr. Parker then 
put in his finger through the opening in the chest-wall and found large 
flakes of thick membraniform lymph which had to be removed by the for- 
ceps. A large quantity of pus was then expelled, containing smaller flakes 
of lymph, besides pultaceous matter. Listerian precautions were observed 
and the case did well. 

When the effusion of fluid has accumulated to such a degree as seriously 
to hamper the circulation and produce a cyanotic tint of the skin, the 
aspirator should be used at once, as instant relief is required to avert death. 
If, however, the effusion be more moderate and no danger be anticipated, 
the question of operative interference will depend upon the nature of the 
pleural contents, and the presence or absence of signs of absorption. If 
the fluid be purulent there is no likelihood of a spontaneous cure by ab- 
sorption. Therefore retention of the purulent contents can in any case 
only do harm ; and in children with tubercular or scrofulous tendencies a 
collection of pus should not be allowed to remain in the chest a day longer 
than is necessary. Even if the fluid be still serous, it is well to remove it 
if after three weeks no sign of absorption has been noticed. In many of 
these cases the serous fluid is not renewed after emptying the chest ; and 
often if only a portion of the contents be evacuated the remainder is 
rapidly taken up by the absorbent vessels. 

In cases of empyema it is best in the first instance to employ the aspi- 
rator, as sometimes after the chest-cavity has been evacuated by this means 
the fluid is not reproduced. During the operation the child should be in 
a semi-recumbent position, supported by the nurse, and the needle should 
be introduced, as recommended by Bowditch, in an interspace immediatelv 
below the inferior angle of the scapula, unless the empyema be loculated. 
The operation often provokes cough ; but this may be disregarded unless 
it grow excessive, in which case the needle may be withdrawn. If there 
be any sign of faintness, we should at once remove the aspirator and close 
the wound. 

Sudden death, although fortunately a very uncommon catastrophe, is 
sometimes a consequence of the rapid withdrawal of fluid from the chest. 
The accident may arise from syncope, from rapid interference with the 
function of the healthy lung, or from cerebral embolism. If the effusion 
have been copious enough to produce marked cardiac displacement and 
interfere with the circulation through the large vessels, the muscular sub- 
stance of the heart may be in a state of temporary mal-nutrition from having 
been supplied for some time with imperfectly purified blood. The sudden 
withdrawal of the pressure, combined with the slight shock of the opera- 
tion, may so impress the weakened organ as completely to paralyse its 
action ; or if this be borne without result, a sudden movement of the pa- 
tient which throws extra work upon the circulatory centre may prove 
fatal. 

Death sometimes occurs through asphyxia. The disappearance of fluid 
from the pleura is followed by an afflux of blood to the capillaries not only 
of the lately compressed lung, but also of that on the sound side ; for the 
latter has been likewise relieved from pressure by the return of the heart 
and mediastinum to their normal position. If the afflux of blood becomes 
a distinct congestion, acute oedema may result, unless the vessels retain 
sufficient tonicity to enable them to resist the abnormal pressure. Again, 
cerebral embolism may occur, as in a case reported by M. Vallin, in which 
this observer attributed the catastrophe to the sudden disengagement of 



PLEURISY — TREATMENT. 459 

fibrinous clots which had formed in the pulmonary veins of the affected 
side. Such clots are liable to become detached as a consequence of ex- 
pansion of the lung, of a sudden movement, or of washing out of the pleu- 
ral cavity. 

If after one or more applications of the aspirator we find that purulent 
fluid is always reproduced, or if the fluid withdrawn is fetid, it is better to 
make an opening in the chest and introduce a drainage-tube. Opinions 
are divided as to whether a single or double opening is to be preferred. 
If a single opening allows of perfect evacuation of the pleural cavity, it 
seems to be preferable to a double aperture, for the drainage-tube passing 
from one opening to the other may, as Dr. Allbutt has suggested, act as a 
seton and keep up a constant irritation. If a single opening be made, the 
spot selected should be at some point on a level with the lower angle of 
the scapula. One end of the drainage-tube should be passed through the 
opening, and the other may be allowed to dip into a large bottle half full 
of water. The operation should be performed with antiseptic precautions. 
If chloroform be given, great care must be exercised in its administration. 
It is better to do without anaesthetics and produce local insensibility by 
freezing the skin at the site of the operation. 

After the tube has been inserted the chest should be bound round with 
an antiseptic binder, and the pleural cavity may be left to drain itself. It 
will not be necessary to wash it out with disinfecting solutions unless signs 
of decomposition have been noticed. If, however, the pus which flows 
after the operation is fetid, injections of a solution of iodine may be em- 
ployed, diluting one drachm of the tincture with one ounce of water ; or 
carbolic acid may be used diluted with thirty times its bulk of water. This 
measure will not be required when the pus continues to be perfectly sweet. 
In such cases the introduction of antiseptic solutions seems to keep up 
an irritation which it is desirable to avoid. Moreover, the operation is 
usually distressing to the patient, and is not without danger, for syncope 
and other alarming symptoms have sometimes been seen to follow the in- 
troduction of the fluid. In cases where the empyema is fetid, Mr. B. W. 
Parker recommends a double opening to be made in the chest- wall through 
which the drainage-tube can be threaded, and prefers, to injections of an 
antiseptic fluid, placing the child daily in a warm bath with sufficient 
depth of water to cover the upper opening. The water can be medicated, 
if desired, by a weak antiseptic solution. It is needless to say that all in- 
struments used in operation upon such cases should be scrupulously clean 
and be carefully disinfected before use. 

Complete drainage of the cavity is followed in most cases by great im- 
provement in the condition of the child. His temperature, if it had been ele- 
vated, falls ; his appetite improves ; and if diarrhoea had been present, the 
stools become fewer in number and much healthier in appearance. Any after- 
elevation of the temperature or return of the signs of distress and irritation 
should lead us to suspect some retention of fluid in the pleural cavity, or the 
onset of some complication, such as a secondary tuberculosis. In the first 
case it will be well to wash out the chest thoroughly. In the second, special 
measures must be resorted to for the treatment of the complication. If 
secondary tuberculosis have come on, the prospects of the child are most 
gloomy, and little can be done to arrest the downward progress of the dis- 
ease. 

In cases where the above method of drainage fails to bring about 
closure of the cavity, owing to imperfect expansion of the lung or rigidity of 
the chest-walls, which are slow to adapt themselves to the diminished size 



460 DISEASE IN CHILDREN. 

of the organ, resection of a portion of the rib seems often to be of advan- 
tage in helping the disease to a favourable termination. 

In all cases of chronic empyema the strength of the child should be sup- 
ported by a free supply of nourishing food. Meat (pounded if necessary) 
strong meat essence, milk, eggs, etc., should be given in quantities such as 
the patient can digest ; and port wine, St. Raphael tannin wine, or the 
brandy-and-egg mixture should be offered in sufficient doses. Cod-liver 
oil is also, especially in children of scrofulous constitution, an important 
addition to the treatment. 



CHAPTER YIL 

COLLAPSE OF THE LUNG. 

Collapse of the lung is a common lesion in infancy. In some new-born 
babies the lungs after birth are imperfectly expanded so that the alveoli 
over a larger or smaller area remain closed as in the foetal state. This 
variety is called congenital atelectasis. In other cases, although perfect ex- 
pansion has been effected after birth, and the respiratory functions have 
been thoroughly established, collapse is induced in the lung as a conse- 
quence of disease, and a tract of variable extent becomes again condensed 
and airless. The latter lesion, which is called post-natal atelectasis is more 
common than the former, and indeed is one of the most familiar of pul- 
monary lesions in the young child. These varieties will be considered 
separately. 

CONGENITAL ATELECTASIS. 

This variety of pulmonary collapse was first described in the year 1832 
by Dr. Edward Jong, who gave it the name which it still retains. Congen- 
ital atelectasis rarely occurs except in feeble infants, such as have been 
born prematurely, or are the offspring of weakly mothers, or have entered 
life under conditions unfavourable to the efficient establishment of the re- 
spiratory functions. A tedious labour producing long compression of the 
cord ; too energetic uterine contractions causing a too early separation of 
the placenta from the womb ; a low temperature of the external air ; a high 
temperature with imperfect ventilation and deficiency of oxygen — the im- 
perfect expansion has been attributed to all these causes. In addition, the 
presence of mucus or fluid in the air-tubes may act as a direct mechanical 
impediment to the entrance of air and prevent the inflation of a part of the 
pulmonary tissue. 

Morbid Anatomy. — On inspection of a lung which is the seat of this 
lesion the unexpanded portion is at once recognised by its dark red or 
purplish colour, contrasting with the rosy tint of the inflated tissue. Be- 
ing perfectly airless, it looks shrunken and depressed, does not crepitate 
when squeezed, and feels tough and dense like soft leather. If a portion 
be cut out and placed in water, it sinks instantly to the bottom of the 
vessel. On examination of the cut surface with a lens, the outline of the 
air-cells may be visible ; but if the child have survived for some weeks, 
the vesicular structure can often hardly be perceived. The parts of the 
lung which thus remain airless after birth are most commonly the least 
bulky portions, such as the thin lower borders of the lobes, especially the 
inferior lobes and the middle lobe of the right lung. Often, however, the 
collapse is not confined to these parts, but extends for some distance over 
the posterior surface, and penetrates pretty deeply into the organ. 

If the child die early, the unexpanded lobules can be readily inflated 
after death by a blow-pipe passed into the bronchus ; but if life has been 



4G2 DISEASE IN CHILDREN. 

prolonged for a period of weeks, re-inflation is not so easy and may only 
be effected by the expenditure of considerable force. 

In cases of congenital atelectasis other parts besides the lungs often 
remain in the foetal state. The foramen ovale is usually open, and perhaps 
the ductus arteriosus may still remain unclosed. 

Symptoms. — In a new-born infant, when expansion of the lungs is im- 
perfect, the child is usually small and ill-nourished. His appearance and. 
manner show great want of power, and his muscles feel soft and flabby. 
His complexion is dirty white or pale, with lividity about the eyelids and 
mouth. He lies quietly without movement, and seems very apathetic, 
seldom attempting to cry. If he do, he utters only a feeble whimper and 
never makes a loud sound. Often he merely draws up the corners of his 
mouth without making any sound at all. The fingers and toes are of a 
dark red or purple tint, and feel cool to the touch ; indeed, the internal 
temperature of the child is below the normal level, and often reaches only 
97.5° in the rectum. The respiratory movements are not laboured ; on 
the contrary, they are shallow and short, and evidently expand the chest 
very imperfectly. As in all cases where the bases of the lungs fail to ex- 
pand in a young child, the corresponding ribs sink in to a certain extent 
at each inspiration. Still, on account of the feebleness of the inspiratory 
movements the depression at the bases is less noticeable than it is in some 
other diseases. When put to the breast the child is unable to suck, and 
has to be fed with a syringe or a spoon. Sometimes he cannot swallow. 
The pulse is very feeble and the fontanelle is more or less deeply depressed. 
A warm bath seems to revive the child for the time, and even gives a little 
colour to the skin ; but after removal the infant sinks into his former de- 
pression. 

An examination of the chest furnishes little information. If the un- 
expanded area is small, we may detect no sign to indicate the nature of 
the lesion. There may be a little want of resonance at the bases of the 
lungs posteriorly ; but on account of the small size of the thorax at this 
period of life, and the facility with which sounds are conveyed from one 
part to the other, the vesicular murmur may appear to be as loud at the 
bases as at any other part of the chest. It is only in cases where the col- 
lapse is very extensive that any suppression or alteration of the respiratory 
sound can be detected. 

The after- symptoms vary according to the extent of the useless portion 
of the lungs. If this be considerable, the weakness continues ; the breath- 
ing remains shallow and short ; lividity increases ; the eyes are motionless ; 
the pupils dilated, and the skin is cool. Soon the temperature falls still 
further, twitches and spasmodic movements are noticed in the face and 
limbs, and the child sinking into a state of stupor, dies asphyxiated on the 
second, third, or fourth day. 

In the less severe cases, or in cases where judicious treatment has suc- 
ceeded in increasing the area of inflated tissue, the child at first may seem 
to be going on well, although he never exhibits in his movements the vigour 
of one whose lungs are well expanded. His movements are more or less 
languid, and he sucks feebly or cannot be persuaded to take the bottle or 
the breast. After a time he seems to grow weaker and can only be kept 
warm with difficulty. His respirations get more and more shallow and 
his cry feebler. The child is always sleepy, and lies dosing with livid 
mouth and eyelids, the latter often incompletely closed. The fontanelle 
is depressed. From this point he may sink gradually and die after a 
series of convulsive fits, or may be roused by energetic treatment which 



COLLAPSE OF THE LTT^G — SYMPTOMS — PEOG1STOSIS. 463 

again inflates the closed air-cells. But in such a case, although the child 
may be apparently restored, the unfavourable symptoms usually return, and 
it is rare for the patient to recover. In most cases after a time remedies 
seem to be useless and the infant can no longer be revived. Thrombosis 
of the cerebral sinuses, according to Stiffen, is often found in these cases. 

Even in cases where recovery is apparently complete, the lung is not 
always perfectly expanded, and a slight catarrh may cause sudden and 
unexpected death. Mr. W. Burke Kyan has related the case of a child, aged 
five weeks and in good condition, who one evening was noticed to cough, 
and the next morning died quite suddenly. On examination of the body, 
both lungs were found to be shrunken and firmly contracted so as to 
leave the greater part of the pericardium exposed. They sank instantly in 
water ; and when cut into little pieces, not the smallest bit floated. An 
examination with a small lens showed no trace of cellular structure, and an 
examination by Mr. Quekett of small sections with a higher power dis- 
covered many of the alveoli to be filled up by small granules or cells which 
rendered them solid. 

Cases of congenital atelectasis which recover completely are usually 
those in which energetic treatment has been adopted within a few hours 
of birth and has resulted in healthy inflation of the whole lung. In the 
beginning this may be often accomplished ; but delay leads to such change 
in the closed air-cells that they can be rarely sufficiently inflated to take 
useful part in the respiratory process. Moreover, from the observations of 
F. Weber and Stiffen, it appears that in cases where the child survives with 
permanent atelectasis of a portion of the lungs, the constant obstruction to 
the pulmonary circulation leads to hypertrophy of the right side of the 
heart, prevents the closure of the foramen ovale and ductus arteriosus, and 
may eventually induce hypertrophy of the left auricle and ventricle. 

Diagnosis. — The history of these cases reveals a constant state of weak- 
ness and torpor. This want of power, combined with lividity of the face, 
inability to suck, shallow breathing, and low temperature, is very suggestive. 
If in addition we notice the signs and symptoms of imperfect expansion of 
the chest, and on a physical examination fail to find evidence of marked 
consolidation, we can have little difficulty in ascribing the symptoms to 
their true origin. 

Prognosis. — The prospect of recovery depends partly upon the cause of 
the atelectasis, partly upon the strength of the child, and partly upon the 
period after birth at which restorative measures are adopted. If the im- 
perfect expansion of the lungs be due to some obstacle in the tubes them- 
selves, or to some temporary accident occurring at the time of birth, the 
child's strength is usually good and treatment employed promptly is gen- 
erally successful. If, however, means are not adopted early to enforce ex- 
pansion of the unused alveoli, the prognosis is little less unfavourable than 
when the atelectasis is due to general weakness of the patient. In the 
latter case the chances of permanent improvement are not good, but vary 
according to the strength of the child. The unfavourable signs are : in- 
ability to suck ; increasing lividity ; a sub-normal and falling tempera- 
ture and great apathy of manner. If the child ceases to be able to swallow, 
or if tonic or clonic spasms are noticed in the muscles of the face or limbs, 
we can entertain little hope of his recovery. 

Treatment.— When a child is born apparently lifeless after a tedious 
labour measures must be at once adopted to promote efficient expansion 
of the lungs. It is important, however, that whatever is done should be 
done with due deliberation and care, avoiding unnecessary hurry or vio- 



464 DISEASE IN CHILDKEN. 

lence. In a new-born infant the organs are especially tender, and may be 
fatally injured by heedless energy. Cases have been met with in which 
the liver and spleen have been ruptured by an over-zealous practitioner in 
his haste to promote inflation of the lungs. The chest of a new-born 
infant is in a state of absolute airlessness ; and therefore methods of resus- 
citation which depend for their success upon elastic recoil of the chest- 
walls are without any value. So, also, the method of mouth-to-mouth 
insufflation, pressing at the same time the larynx backwards against the 
gullet so as to close the latter passage, fails to introduce air into the lungs. 
Dr. F. H. Champneys, from a series of elaborate experiments upon the 
bodies of new-born infants, concludes that the best method of resuscitation 
is that of Dr. Silvester. The child is laid on his back on a table with a 
pillow under his shoulders, and the operator standing behind the body 
grasps the arms above the elbows and everts them. He then in successive 
movements raises the arms upwards by the side of the child's head ; ex- 
tends them gently upwards and forwards for a few seconds ; then turns 
them down and presses them gently and firmly for a few moments against 
the sides of the chest. While this is being done the tongue should be held 
forwards by an assistant. The movements should be repeated fifteen times 
in the minute, and should be continued for at least half an hour if no satis- 
factory result be previously obtained. 

M. Greult advocates placing the infant in water as hot as the hand can 
bear — which he finds to be about 113° F. — and employing artificial res- 
piration while the child remains in the bath. He relates the case of a 
primipara who after a tedious labour was delivered by forceps. The 
infant, when born, was breathless, cold, with scarcely any movement of the 
heart and but feeble pulsation in the cord. The child was at once placed 
in water which felt burning hot to the hand, and artificial respiration was 
begun. At the end of one minute the skin reddened, and a slight move- 
ment of the chest indicated the beginning of respiration. At the end of 
two minutes the child began to cry, to breathe, and to move his limbs. 

In cases where the infant breathes, but is evidently labouring under 
imperfect expansion of the lungs, he should be warmly covered or even 
wrapped in cotton wool, and kept perfectly quiet in a room heated to a tem- 
perature of 70° or 75.° The best position is that recommended by the late 
Dr. C. D. Meigs, viz., upon the right side with the head and shoulders 
raised at an angle of 45°. If the patient cannot suck he should be fed with 
breast milk or some efficient substitute, as directed elsewhere (see page 
603). The food must be given with the syringe and elastic tube (see page 
15 ). Stimulants are indispensable. Five drops of brandy can be given 
in a sj^ringeful of the food every two, three, or four hours, or the child may 
be fed with white wine whey. If the lividity increases and other unfavour- 
able signs are noticed, attempts should be made to force the child to cry or 
gasp by slapping the chest with the corner of a towel wetted with cold 
water. Emetics are also useful in freeing the tubes of mucus and forcing 
the patient to respire deeply. Sulphate of copper (a quarter of a grain 
in a teaspoonful of water) is the best form in which they can be given. 
Emetics, however, must not be used if the child is very feeble. 

Stimulating embrocations rubbed into the chest are often of service, and 
immersion in a strong mustard bath (one ounce of mustard to each gallon 
of water) until the skin becomes very red is a stimulant of very powerful 
efficacy. The internal administration of stimulants should be continued as 
long as the child is able to swallow. Unfortunately in bad cases the results 
of all these measures are far from encouraging. 



COLLAPSE OF THE LUNG — TKEATMENT. 465 



PQST-tfATAL ATELECTASIS. 

The form of collapse of the lung which occurs in infants whose lungs 
have been fully expanded at birth is a very common lesion. It occurs 
almost invariably in the course of a pulmonary catarrh, and is one of the 
accidents which render this form of derangement so fatal in weakly or 
rickety children. 

Causation. — The immediate cause of collapse of the lung is the presence 
in the bronchial tubes of mucus which the child is unable to expel by reason 
of feebleness of the respiratory apparatus. Dr. Gairdner, of Glasgow, 
in his treatise explains very clearly the mechanism by which exhaustion of 
the lobules is effected. In the act of inspiration a plug of mucus is carried 
inwards along a tube the calibre of which is constantly diminishing. When 
the narrowness of the tube prevents further advance, the mucus forms a 
plug which completely obstructs the channel. During expiration the plug 
is slightly dislodged so as to permit of the escape of some of the air con- 
tained in the lobule ; but at each inspiration it is again drawn backwards 
so as to close the tube completely against any air entering to replace that 
which has just escaped. In this manner after a time the lobules beyond 
the point of obstruction are completely exhausted and the tissue becomes 
shrunken and condensed. Even if the plug of mucus be completely im- 
pacted in the tube so that it cannot be dislodged during expiration, col- 
lapse may still occur, for the pent-up air in the alveoli is exposed to such 
pressure by the elasticity and contractility of the alveolar parieties that it 
is absorbed. 

The retention of mucus in the tubes is the consequence of inability to 
cough it away, and any cause which diminishes the energy of the inspiratory 
act increases the difficulty of drawing in air past the impediment in the 
bronchus. New-born dnf ants do not know how to cough, for the act of 
coughing is only partly involuntary. It is in part an effort of volition to 
remove an obstacle to the free passage of air in the tubes. An infant who 
has not acquired a knowledge of the means by winch the impediment may 
be expelled, suffers the obstruction to remain without employing the nec- 
essary force to effect its removal. Even if the child knows how to cough, 
he may not have the power to carry out the act with sufficient energy to 
make it effectual. In the act of coughing a full inspiration is first taken. 
The glottis is then closed, and pressure is brought to bear upon the lungs 
by the muscles of expiration. While this pressure is at its height the 
glottis is relaxed, and the rush of air passing out carries with it the mucus 
which w r as obstructing the tubes. If, however, the lungs cannot be suffi- 
ciently filled, or if, owing to weakness of the patient, the force of the expi- 
ratory muscles is insufficient to bring adequate pressure to bear upon the 
lungs, the cough is ineffectual in freeing the tubes of their contents. 

W T eakness of the inspiratory act is a powerful agent in preventing the 
entrance of a sufficient supply of air. In ordinary respiration the elastic- 
ity and contractility of the lung have to be overcome by the muscles of in- 
spiration. If these muscles are feeble, as they are in a weakly infant, the 
obstacle to efficient inflation of the lungs is already great. If, however, in ad- 
dition, the respiratory muscles are opposed by reflex contraction of the bron- 
chial muscles, owing to the irritation of the catarrhal process, and also by 
mucus in the tubes, they may prove quite unequal to the task. Therefore 
any cause which increases the child's general weakness predisposes to pul- 
monary collapse. Thus vomiting, diarrhoea, insanitary conditions, im* 
30 



466 DISEASE Itf CHILDBED. 

proper feeding, and all the exhausting forms of illness may have this 
result. 

Besides the causes which have been enumerated, the force of the in- 
spiratory act may be weakened by mechanical means. Interference with 
the action of the diaphragm may have important consequences in this re- 
spect. This influence is especially seen in the case of young infants. For 
some time after birth respiration is principally diaphragmatic on account 
of the circular shape of the chest, which allows of little lateral expansion. 
Therefore any resistance to the descent of the diaphragm, such as would 
be produced by ascites, or great increase in size of the abdominal organs, 
or flatulent distention, may so weaken the force of the inspiratory act that 
a very trifling catarrh determines wide-spread and fatal collapse of the lung. 

Another mechanical means by which the force of the inspiratory act 
may be interfered with is deficient rigidity of the chest-wall. Abnormal 
softening of the ribs is a very important agent in the production of col- 
lapse, and the frequency and danger of the lesion in rickety subjects is 
mainly owing to this simple cause. The parieties of the chest in the infant 
are naturally more flexible than they are in the adult. Even when the 
ribs and their cartilages are perfectly sound, considerable recession of the 
lower ribs may be seen at each inspiration if an impediment exist at any 
part of the air-passages to interfere with the ready entrance of air into the 
lung. If the ribs are softened, as in rickets, the same recession is noticed 
although the passages may be perfectly free ; for the softened ribs cannot 
resist the pressure of the atmosphere, and the force of the inspired air is 
insufficient by itself to prevent the thoracic parieties, where least supported, 
from sinking in. Consequently in this disease the lower lobes of the lungs 
are very insufficiently filled with air. If such a child suffer from pulmonary 
catarrh, the additional obstacle to efficient inspiration created by the mucus 
in the tubes may lead to complete collapse of the inferior parts of the 
lungs. On account of the mechanism by which it is produced, collapse of 
the lung must always be a secondary lesion. It is found as a complication 
of various forms of illness. Diseases of which pulmonary catarrh is a 
common symptom, as whooping-cough and measles ; diseases which interfere 
directly with the passage of air through the glottis, as diphtheria, laryngitis 
stridulosa, post-pharyngeal and other abscesses in the neighbourhood of 
the larynx ; diseases which diminish the force of the inspiratory act, either 
by mechanical opposition as in abdominal tumours and rickets, or by im- 
pairing the muscular strength of the patient — in all these cases collapse 
of the lung is liable to be found. 

Morbid Anatomy. — The extent of the collapsed area is in proportion to 
the calibre of the tube at the point of obstruction. According, therefore, 
as the lesion involves many lobules over a considerable surface, or is 
limited to a few, the collapse is said to be diffused or lobular. The airless 
part of the lung is shrunken and therefore depressed. It is purple in 
colour and to the touch feels soft and dense. It does not crepitate. On 
section the surface is smooth, and blood or bloody serum exudes on press- 
ure. Around the collapsed portion the air-cells are emphysematous. 

Lobular collapse is often situated at the anterior edges of the lungs, 
but may occupy any other parts. The diffused variety is most common at 
the posterior surface, but may be seen elsewhere. It penetrates for a 
variable distance into the organ, and sometimes an entire lobe or even the 
greater part of the lung may be found shrunken and airless. After death, 
if the lesion be recent, the collapsed tissue can be completely reinflated 
through .the bronchus. 



POSTNATAL ATELECTASIS — SYMPTOMS. 467 

Symptoms. — The symptoms are found to vary considerably in different 
cases according to the extent of the collapse and the degree of strength of 
the patient. In a very weakly infant rapid and extensive collapse is often 
a cause of sudden death. In such cases the preliminary catarrh is not 
necessarily severe. Often, indeed, it is trifling ; and the rapidity with 
which death occurs gives rise to much surprise and consternation. The 
impaction in a large bronchus of a single plug of mucus may be thus fol- 
lowed in a young and feeble subject by rapidly fatal consequences. An- 
other common result of the lesion is a convulsive seizure ; and sometimes 
the fits succeed one another with great rapidity, each attack increasing the 
exhaustion of the patient and aggravating the pulmonary mischief until 
death ensues. These cases are not, however, always immediately fatal. 
In a sensitive child collapse of comparatively limited extent, if it occur 
suddenly, may give rise to an eclamptic seizure ; but this may not be re- 
peated, and perhaps by judicious and energetic treatment the child's life 
may be saved. 

Such severe symptoms are, however, exceptional. In most cases the 
occurrence of collapse is indicated by less striking phenomena. A weakly 
infant is suffering from the ordinary symptoms of bronchial catarrh. He 
coughs more or less loosely and his breathing is moderately hurried, but 
there is nothing to excite apprehension. Suddenly, however, a change oc- 
curs. The child becomes restless and evidently distressed ; his face gets 
distinctly livid, especially about the eyelids and mouth ; his breathing, 
which had been more laboured than natural, increases in rapidity but di- 
minishes in depth ; the cough ceases or is feeble and faint ; and the inter- 
nal temperature of the body is found to be below the level of health. 

The face usually indicates profound depression. The features look 
pinched ; the eyes are dull and hollow ; and the forehead is often moist 
with a cool, clammy perspiration. The nares act in respiration, and the 
breathing is very rapid. The number of respirations commonly reaches 
70 or 80 in the minute, and the perversion of the pulse-respiration ratio is 
extreme. In very young infants the breathing is usually very shallow, 
with little movement of the chest-walls ; but in infants eight or nine 
months old, whose ribs are softened by rickets, the bases of the chest sink 
in to some extent at each inspiratory movement. The child refuses to suck 
and often seems to have difficulty in swallowing, so that he can hardly be 
persuaded to take milk from a spoon. 

The physical signs, if any are to be discovered, consist in slight dul- 
ness at the posterior base of one lung, or extending upwards in a narrow 
vertical strip at each side of the spine. The dulness can often only be 
discovered by very gentle percussion, as a sharp blow with the finger brings 
out the resonance from healthy tissue underlying the condensed layer. 
The breathing conducted from healthy tissue around is of bronchial quality, 
and may be weak or fairly loud, according to the strength of the respiratory 
movement. Vocal resonance is usually annulled. Sometimes coarse crep- 
itation is heard at the confines of the collapsed area. These signs are only 
to be discovered when the lesion is of the diffused variety. In lobular col- 
lapse any dulness which may be occasioned by the presence of the solidi- 
fied patches is neutralised by the compensatory emphysema set up in their 
neighbourhood. 

When the above symptoms and signs are noticed, the infant's condition 
is a very serious one ; and unless prompt measures are taken to excite ex- 
pansion of the collapsed tissue and expel the obstructing mucus, death 
must inevitably ensue. The lividity increases or changes to an ashy hue. 



468 DISEASE IN CHILDEEN. 

the breathing grows more arid more shallow, and the child dies in a state 
of stupor from slow asphyxia, or expires in a convulsive attack. 

In children over a year old, who are not the subjects of rickets, the 
symptoms are usually less severe, and the physical signs more nearly re- 
semble those which exist under similar circumstances in the adult. If the 
ribs are softened from rickets, the impediment thus raised to efficient in- 
spiration greatly aggravates the effects of limitation of the respiratory sur- 
face, and in children as old as two or three years the signs of suffering are 
well marked. If, however, the chest-wall preserves its normal rigidity, the 
symptoms are much less characteristic. The respiration may be hurried, 
although this is not always the case, and the complexion may show some 
signs of deficient aeration of the blood ; but the child is not prostrated by 
the lesion ; he can cry fairly loudly, and his cough is not suppressed. On 
examination of the chest, we find dulness of variable extent on one side, 
usually at the base ; the respiration is weak and harsh over the same area 
with absence of vocal resonance, and large moist rales are heard about the 
back. In some cases, as when the collapsed area immediately surrounds 
a large bronchial tube, the rhonchus may be metallic and ringing as if 
produced in a cavity. 

If the lesion occupy the apex, the breathing is often loud and bron- 
chial or blowing, and the dulness may be complete. In this situation col- 
lapse is very likely to be mistaken for consolidation arising from other 
causes. 

A rickety little boy, aged eighteen months, who had cut only sixteen 
teeth, was being treated in the East London Children's Hospital for chronic 
diarrhoea arising from ulceration of the bowels. The chest was not de- 
formed and there was no softening of the ribs. An elder sister had died 
in the hospital from tubercular peritonitis. About a week after the child's 
admission he began to cough, and in a few days it was noticed that the 
percussion-note at the right supra-spinous fossa was decidedly high-pitched, 
and that the respiration there had a faint bronchial quality. There was a 
little coarse bubbling about the back on each side. The temperature had 
been generally about 100° at night, sinking to 99° in the morning. The 
pulse was 96-100 ; the respirations 26-30. 

Some days afterwards dulness at the right apex behind had become 
complete, and the breathing was bronchial with a click in the middle of 
inspiration. In front the percussion-note was quite healthy. The moist 
rales over the back persisted. Temperature in the evening, 99°-100° ; 
pulse, 80-102 ; respirations, 20-30. All the time the diarrhoea continued 
and the child wasted rapidly. There was more or less general oedema. 
The urine was albuminous and contained renal epithelium. A few days 
afterwards the child died quietly. 

On examination of the body, both lungs were found to be emphyse- 
matous with scattered patches of lobular collapse. At the posterior part of 
the apex of the right lung was a patch of collapse which occupied the up- 
per third of the lobe. Ulcers were found in the lower part of the sygmoid 
flexure and rectum. The kidneys were congested. There was no sign of 
gray granulations or of caseous nodules anywhere about the body. 

This case was mistaken for one of acute tuberculosis with tuberculous 
ulceration of the bowels. The moderate pyrexia, the oedema, the albumi- 
nuria, and the increasing signs of consolidation of the right apex seemed 
to justify this view, especially when considered in relation to the history of 
tubercular peritonitis in the elder sister. 

In some cases of lobular collapse where the symptoms are not very 



POST-NATAL ATELECTASIS— SYMPTOMS — DIAGNOSIS. 469 

severe, a considerable change all at once is found to occur. The tem- 
perature rises, the breathing becomes laboured, and the lividity and signs 
of distress increase. These symptoms indicate the beginning of catarrhal 
pneumonia. 

Sometimes after an attack of pleurisy the lung is left condensed and 
airless and adherent to the chest-wall, without any marked contraction of 
the side. This condition may produce very puzzling physical signs. 

A little girl, aged fourteen months, with eleven teeth, was said to have 
been a fine child until the age of ten months. At that time she had begun to 
suffer from a cough which was called whooping-cough by the medical at- 
tendant. The child was brought to the hospital for the cough, which had 
continued for four months, and for general wasting of two months' stand- 
ing. On examination, although there was no obvious contraction of the 
right side of the chest, the respiratory movement of that side was seen to 
be impaired. The lower intercostal spaces, however, sank in fairly w T ell, 
although less deeply than on the opposite side. On percussion, complete 
dulness with increased resistance was found over the greater part of the 
right side. It extended over the w T hole posterior region, and reached up- 
wards in the axilla to the second rib, and in front to the third. Towards 
the spine behind the note had a wooden quality. Posteriorly and laterally 
the breath-sounds were cavernous with abundant crisp, clicking sounds. 
In front the breathing was bronchial. The resonance of the cough was 
abnormally strong. 

On the left side there was no dulness, but the breathing was blowing 
towards the apex, and some clicking rhonchus was heard all over the left 
back. The heart's apex was in the fourth interspace slightly to the outer 
side of the left nipple line. The edge of the liver could be felt one inch 
below the ribs. 

The chest was twice explored with a fine aspirating syringe, but no fluid 
could be detected. The child eventually died. Her temperature until 
shortly before death was normal. 

On examination of the body the right lung was found to be much 
shrunken and to be universally attached by old but readily separable ad- 
hesions to the chest-wall. It was almost entirely non-crepitant, and felt 
very tough and firm in texture. Inflation only partially succeeded in dilating 
the condensed tissue and much force had to be employed. On section the 
texture of this lung was found to be throughout excessively tough and firm. 
It was thought there was some slight dilatation of the bronchi. A few nod- 
ular caseous masses were found scattered over the parenchyma. The left 
lung was generally emphysematous, with the exception of the inferior part of 
the lower lobe, which was collapsed, but could be reinflated with the blow- 
pipe. This lung passed across the middle line of the chest and encroached 
largely upon the right pleural cavity. On section it was pale and contained 
little blood. The kidneys looked fatty. The heart and other organs 
appeared to be healthy. 

This case had been, no doubt, one of pleurisy in which the effusion had 
become absorbed, leaving the lung in a state of condensation and collapse, 
similar to the gray induration described by Addison. The physical signs 
were very similar to those of fibroid induration of the lung ; indeed, this 
was the opinion expressed as to the nature of the case, in spite of the tender 
age of the patient. 

Diagnosis. — When the collapse assumes the lobular form, the diagnosis 
has to be made without the aid of physical signs. In a well-marked example, 
however, the symptoms are so characteristic that an accurate opinion can 



470 DISEASE IN CHILDREN. 

be formed without much hesitation. Our conclusion is based upon the fact 
that in the course of a pulmonary catarrh signs are suddenly observed in- 
dicating feebleness of inspiratory power and deficient aeration of the blood. 
Thus, a weakly or rickety infant, who has been noticed to cough for a day 
or two, all at once begins to exhibit signs of restlessness and distress. His 
cough ceases, his cry is replaced by a feeble whimper or a mere distortion 
of the features without sound ; the eyes are hollow ; the complexion is livid ; 
the nares act ; the breathing is shallow and is hurried out of proportion to 
the pulse and the temperature is low. 

If pulmonary catarrh attack a feeble infant, we must always be prepared 
for the establishment of collapse, and the sudden occurrence of the symp- 
toms enumerated, combined with a low temperature and the absence of all 
physical signs connected with the chest, leaves us no other explanation of 
the child's condition. The only other disease which would be accompanied 
by a similar train of symptoms and an equal perversion of the pulse respi- 
ration ratio, without any abnormality of the physical signs, is acute bron- 
cho-pneumonia. In this disease, however, the temperature is high, the 
breathing very laborious, and the cough loud and hacking. In pulmo- 
nary collapse the temperature is normal, or even below the natural level of 
health ; the cough is feeble or suppressed, and the breathing is shallow ; 
for even if there is recession at the base of the chest from rickets, there is 
no laboured movement of the shoulders or upper part of the thoracic wall. 

A difficulty sometimes arises from the slightness of the pulmonary 
catarrh. The cough may be unnoticed by careless attendants, and the 
occurrence of such symptoms without being preceded by any history of 
cough may excite some surprise. It is necessary, therefore, to remember 
that atelectasis may be the consequence of a very slight catarrh, and that 
we are justified from the symptoms alone, and without the presence of 
physical signs, in drawing the conclusion that the child is suffering from 
collapse of the lung. 

"When lobular collapse occurs in the course of an attack of mild bron- 
chitis, the presence of the lesion may be inferred by remarking that the 
symptoms of prostration and deficient oxydation of the blood are exagger- 
ated out of all proportion to the physical signs. If the bronchitis be severe, 
we may conclude that atelectasis is present if the breathing becomes sud- 
denly shallow and rapid ; if the cough and cry become suppressed ; while 
the lividity and general distress are still further aggravated, and the in- 
ternal temperature of the body falls below the level of health. 

In cases of diffused atelectasis an examination of the chest reveals 
dulness, bronchial breathing, and a sub-crepitant rhonchus. The disease 
may then be mistaken for croupous pneumonia or pleurisy. In a young 
infant, however, little hesitation is occasioned, for the symptoms induced 
by atelectasis are very different from those resulting from either of the 
diseases which have been mentioned. It is principally in cases where the 
lesion occurs after the end of the first year that any perplexity is ex- 
perienced. At this age the general symptoms are usually less severe and 
the child's weakness much less pronounced. Still, the history of the illness 
is very different in collapse from that of a case of inflammation either of 
the lung or the pleura. Moreover, in pneumonia the high temperature is 
a distinguishing mark of great value ; and tubular breathing, with a fine, 
puffy crepitation noticed at the borders of the dull area, are signs which are 
not heard in collapse of the lung. From a localised pleurisy the lesion is 
not always so easily distinguished. Collapse of a mere layer of tissue on 
the surface of the lung gives rise to only moderate dulness quite unlike 



POST-JSATAL ATELECTASIS— PKOGNOSIS— TEE ATMENT. 471. 

fche dead, toneless note over even a thin stratum of fluid. If, however, an 
entire pulmonary lobe be collapsed, the dulness may be very marked and 
the resistance notably increased, although perhaps to a less extent than is 
found in cases of pleurisy ; still, the difference is one only of degree. To 
add to the resemblance, the breathing in either case may be weak and 
bronchial without rhonchus or other adventitious sound. If, however, the 
vocal resonance be cegophonic, the sign is characteristic of pleurisy and 
is never found over merely collapsed lung-tissue. In most cases the 
symptoms alone in the two diseases are sufficiently different to warrant a 
diagnosis. In atelectasis the distress is greater, and the signs of lividity 
are more noticeable than in the case of pleurisy of equal extent ; for in 
the latter disease, unless a great accumulation of fluid occur, or the pain 
be severe, the child, as a rule, appears little inconvenienced by his illness. 

When the collapse occupies the apex of the lung, as in the case narrated 
above, it is often distinguished with difficulty from an ordinary caseous 
consolidation, especially if any complication be present, as in that case, to 
raise the temperature of the body above the natural level. Still, one dis- 
tinguishing mark which was present in the case referred to might suggest 
simple condensation of tissue, viz., the limitation of the dulness to one 
aspect of the chest. Complete dulness arising from consolidation would 
be certainly accompanied by a corresponding alteration of the percussion- 
note on and above the clavicle as well as at the supra-spinous fossa. 

Prognosis. — Post-natal atelectasis is always a grave lesion, especially in 
weakly children. Indeed, if the collapse occur in the course of a severe 
attack of bronchitis, and the patient be a feeble or rickety infant under 
the age of twelve months, death may be looked upon as inevitable. Even 
when the preliminary catarrh is less severe, the life of the child is placed 
in great danger ; and if the collapse be extensive, or the softening of the 
ribs extreme, treatment must be very prompt and energetic indeed to afford 
any prospect of success. The occurrence of convulsions greatly increases 
the danger of the case ; and marked apathy and torpor, persistent increase 
of lividity, great shallowness of breathing, and inability to swallow are all 
symptoms of unfavourable import. On the contrary, if the face become 
clearer and the breathing deeper, and especially if the child begin to suck 
his lingers, to take his bottle readily, or to show any interest in what passes 
around him, we may have hopes of his recovery. 

Treatment. — Re-inflation of the collapsed air-cells in cases of atelec- 
tasis can only be effected by measures which increase the vigour of the in- 
spiratory movement. To attain this object we must make use of energetic 
stimulation both internally and externally. The child should be placed 
as quickly as possible in a hot mustard-bath of the strength of one ounce 
of mustard to each gallon of hot water. In this bath he should be al- 
lowed to remain until the arms of the person supporting him begin to 
prick and tingle uncomfortably. After being removed and dried, the 
chest should be wrapped loosely in cotton wool, and the child be laid 
quietly in his cot with head and shoulders raised. The temperature of 
the room should be between 70° and 75°. If any signs are observed of 
accumulation of phlegm in the tubes, an emetic is useful ; and a quarter 
or half a grain of sulphate of copper (according to the age of the child) 
may be given in a teaspoonful of water every ten minutes until vomiting is 
produced. The emetic is also valuable in forcing the child to take a deep 
breath. Mechanical means of increasing the depth of the inspirations 
form an important part of the treatment. The infant should not be al- 
lowed to sleep too long at one time. Drowsiness is one of the commonest 



472 DISEASE IN CHILDREN. 

symptoms of this lesion ; but a careful eye should be kept upon the pa- 
tient during his sleep, and if signs of increasing lividity are noticed, he 
must be taken up and put into a mustard-bath, or made to cry by frictions 
to the soles of his feet or by the application of a strong stimulating lini- 
ment to the chest- wall. The linimentum ammonise of the British Phar- 
macopoeia, diluted, if necessary, with an equal quantity of olive-oil, is very 
useful for this purpose. 

If the child can suck, he snould take white wine whey with cream from 
a bottle. In many cases, however, on account of his inability to draw up 
the fluid through the tube, it is necessary to feed him with the syringe. 
In addition, or as a variety, the child may be fed with milk and barley- 
water with Mellin's food, and five or ten drops of pale brandy must be 
given at regular intervals. In the case of a weakly infant, when the symp- 
toms of prostration are great, the stimulant will be required every half 
hour until the child revives. Older children may take milk, strong beef- 
tea, and the brandy-and-egg mixture. 

The above measures must be put in force directly any signs are dis- 
covered indicating the occurrence of collapse. The earlier special treat- 
ment is begun, the more likely is it to be successful. It is of the utmost 
importance that the child be not allowed to sleep himself to death, as he 
will probably do if left alone. He must be roused at intervals and made 
to inspire ; and our efforts must be continued perseverin gly until signs are 
noted of returning vigour or of improved aeration of the blood. Even 
then he must be carefully watched that he may not relapse, and stimu- 
lation must be continued until all danger has passed. 

Drugs are not of much value in this lesiou. Opium is to be carefully 
avoided. Diffusible stimulants may, however, be given if thought advis- 
able. The best of these is quinine dissolved in sal volatile in the propor- 
tion of one grain to the drachm. Three or four drops of this solution 
may be given occasionally in a spoonful of the food. 



CHAPTEE VIII. 

FIBROID INDURATION OF THE LUNG. 

Fibroid induration of the lung (cirrhosis of the lung, interstitial pneumonia) 
is not very uncommon in children, and is often mistaken for phthisis. The 
complaint gives rise to a chronic derangement of health which is subject 
to marked variations according to the season of the year. In cold and 
changeable weather the patient suffers greatly from attacks of bronchitis 
and catarrhal pneumonia. Consequently, at these times he is apt to be 
feverish and grow pale and thin, even if his life be not put in actual peril. 
In warmer and more settled weather he usually greatly improves and gains 
considerably both in flesh and strength. Cases of very chronic "consump- 
tion," in which the patient is constantly ill and failing during the winter, 
but revives and regains flesh during the summer months, are often exam- 
ples of this form of pulmonary disease. Cirrhosis of the lung rarely at- 
tacks infants. It is usually found in children of five years old and up- 
wards. 

Pathology. — Fibroid induration is always a secondary complaint, and 
usually owes its origin to an attack of inflammation of the lung. Both 
croupous and catarrhal pneumonia tend to promote a multiplication of the 
connective tissue elements ; but in children the fibroid increase is commonly 
due to the lobular form, especially to the subacute variety which is apt 
to follow attacks of measles and whooping-cough. Catarrhal pneumonia 
is always accompanied by dilatation of the bronchi, and this condition of 
the air-tubes favours the catarrhal process. It hinders the escape of secre- 
tion and so maintains a state of continual irritation of the air-tubes and 
their terminal alveoli. As a result, the persistence of the pulmonary in- 
flammation tends to promote a fibroid thickening of the walls of the bronchi 
and air-cells ; the dilatation of the tubes becomes a permanent lesion, and 
this, again, helps in its turn to perpetuate the irritation. 

Croupous pneumonia is less often than the preceding a cause of cirrho- 
sis ; but sometimes, if the disease is protracted, thickening and indura- 
tion may occur in the walls of the alveoli, and the indurating process may 
continue after the original disease is at an end. Weber has reported the 
cases of three children in whom the disease had this origin, for he had 
himself treated the patients for the primary attack of pneumonia. 

Sometimes, although rarely in young subjects, inflammation of the 
pleura may lead to the fibroid overgrowth. It is in cases where the lung- 
has been subjected to long-continued compression that this consequence 
is most likely to occur. The thickening in this form is limited at first to 
the superficial interlobular septa ; but the process may afterwards pene- 
trate more deeply and be accompanied by dilatation of the bronchi. 

Induration of the 'two lungs as a consequence of the inhalation of grit 
in the course of industrial labour is not found in children. Young persons 
under twelve years of age are not exposed to this source of disease ; and 



474 DISEASE IN CHILDBED. 

even in adults whose employment obliges them to breathe continually an 
air filled with irritating particles, disease of the lung thus induced is in- 
variably chronic, and only becomes developed after an exposure extend- 
ing over many years. 

Morbid Anatomy.— On examination of a lung, the seat of fibroid indura- 
tion, a great development is noticed of fibro-nucleated tissue in the walls 
of the alveoli, the interlobular connective tissue, and the bronchial tubes. 
As this increases it involves all the connective tissue of the lung. The or- 
gan becomes excessively dense and shrunken. Its substance is firm and 
tough, and a section shows a smooth or faintly granular surface, iron-gray 
or grayish-red in colour, intersected in all directions by white fibrous 
bands. Dotted over it are white rings of various sizes, which are the di- 
vided walls of thickened and dilated tubes. 

The fibroid material is not spread evenly over the parenchyma, but 
often surrounds islets of more healthy tissue, which are thus separated 
from one another by the dense fibrous bands. Sometimes in the neigh- 
bourhood of the fibroid parts the uninvacled tissue may be emphysematous. 
Small cavities containing cheesy matter or thick purulent fluid are seen 
here and there in the dense tissue. Some of these are dilatations of the 
bronchi ; others are the result of ulceration which has spread from the 
enlarged tubes. Sometimes, as in the case of a child five years old who 
was under my care in the East London Children's Hospital, large expanded 
channels are found radiating from the root of the lung and ending abruptly, 
like the fingers of a glove, at the surface of the organ immediately under- 
neath the pleura. 

When the disease follows upon an attack of croupous pneumonia the 
change principally involves the alveoli. The walls of the air-cells become 
greatly thickened, and in some cases, at least, as in an instance reported by 
Dr. Sidney Coupland, the exudation products filling the alveoli become or- 
ganised into a fibrillated and at first vascularised mesh-work. By this 
means the alveoli are either compressed or filled up, and in either case ef- 
faced ; and as the tissue shrinks, the new vessels which had been devel- 
oped in the growing tissue become obliterated. 

If the cirrhosis originate in a broncho-pneumonia the alveolar walls are 
thickened as in the former case ; but in addition there is great develop- 
ment of fibroid tissue in the walls of the bronchi and in the connective 
tissue between the lobules. In these cases whitish bands are seen radia- 
ting from the thickened walls of the air-tubes. 

When the morbid process starts from the pleura, dense fibrous bands 
pass inwards from the surface. The pleura itself is greatly thickened, and 
the lung-tissue underlying it may be converted after a time into a dense 
fibrous substance. At first, however, the fibroid degeneration is more 
partial than in cases where the disease is the consequence of pneumonia. 

Microscopic examination discovers closely packed wavy fibres in the 
denser portions, or even a homogeneous or faintly fibrillated material with 
a few small round or fusiform cells. 

The alveoli, where not completely compressed and effaced, are either 
empty or are filled with nucleated and epithelial cells, granular corpuscles, 
and granules. 

The bronchi are either obliterated or are greatly thickened and dilated, 
especially in parts where the disease is most advanced. The tubes are in 
some cases regularly enlarged, but sometimes more local dilatations are 
seen forming cavities of various sizes. The lining mucus membrane may 
be ulcerated, and in very advanced cases ulcerative destruction of tissue 



FIBROID INDURATION OF THE LUNG SYMPTOMS. 475 

may have penetrated from these spots into the lung. This form of the 
disease has been called "fibroid phthisis" by Sir Andrew Clark. 

Fibroid induration is usually limited to one lung, the other being 
healthy or emphysematous. It may occupy any part of the organ but more 
commonly affects the base than the apex. 

In addition to the mischief in the lung, disease is often found in other 
parts. The liver, spleen, and sometimes the kidneys may be the seat of 
amyloid degeneration. In some cases the liver has been found to be cir- 
rhotic and the kidneys to be granular. 

Symptoms. — In the early stage of the disease the development of fibroid 
tissue in the lung is accompanied by no special symptoms. The process 
most commonly begins at the end of an attack of catarrhal pneumonia. In 
some children we find a peculiar tendency to recurring attacks of this form 
of pneumonia of very unusual duration. Between the attacks the child 
seems almost well, and an examination of the back detects merely a slight 
impairment of resonance on one side (best detected by "broad percus- 
sion " upon three fingers at once), with perceptible increase in the resist- 
ance. The respiratory sounds, however, are normal. When an attack of 
catarrhal pneumonia comes on, the symptoms and signs are those peculiar 
to that form of inflammation of the lung. If death occur after a prolonged 
attack of broncho-pneumonia, we may find one of the lungs small, shrunken, 
and particularly firm to the touch ; and notice on section that the inter- 
lobular septa and walls of the bronchioles are much thickened, especially 
at the base of the organ, and that the bronchi are dilated. Such a con- 
dition constitutes an early stage of the fibroid change in the lung. The 
incipient fibrosis, beyond conferring a certain high-pitched quality upon the 
percussion note — and this sign is but an indefinite one — gives rise to no 
symptoms. Nutrition is not interfered with, the appetite is good, and the 
temperature is normal. Pyrexia, cough, loss of appetite, and impairment 
of nutrition only occur as a result of an intercurrent inflammatory attack ; 
and at these times only are any pronounced physical signs to be detected 
on examination of the chest. Dulness is then marked and extensive ; the 
breathing becomes blowing or tubular ; and coarse bubbling or sub-crepi- 
tant rhonchus — more or less metallic and ringing according to the degree 
of acute dilatation of the tubes— is to be heard with the stethoscope. 
After each of these attacks the lung is left in a distinctly worse condition 
than before. The fibroid overgrowth increases in the lung ; the bronchi 
get to be permanently dilated ; and the lining membrane of the air-tubes 
becomes the seat of more or less persistent catarrh. 

Even when the fibroid overgrowth has increased to such a degree as 
seriously to impair the usefulness of the lung as a respiratory organ, the 
influence of the disease upon general nutrition maybe comparatively slight 
so long as the chest is free from intercurrent attacks of bronchitis or ca- 
tarrhal pneumonia. Special symptoms arising from contraction of the 
lung and consequent obstruction to the pulmonary and systemic circulation 
are to be noticed ; but if no secondary disease of organs has been induced 
by his illness, the child is often fairly stout and strong. Therefore, in warm 
and settled weather, which brings with it freedom from catarrh, his health 
may afford little subject for complaint ; but in changeable seasons, and es- 
pecially during the winter months, he wastes rapidly and exhibits all the 
symptoms of "consumption." 

When the disease occurs as a sequel to an attack of pleurisy, the early 
symptoms vary according as to whether the pleuritic effusion and conse- 
quent compression of the lung have been moderate or excessive. In the 



476 DISEASE m CHILDREN. 

first case, unless a local catarrh be present the general symptoms may be 
insignificant ; and a physical examination may only detect dulness at the 
extreme base behind, with very weak bronchial breathing and some coarse 
bubbles with respiration. The child may be subject to paroxysmal cough, 
but need not for a long time necessarily suffer in his nutrition through the 
condition of his lung. If, however, effusion have been copious, and the 
lung be bound down by thick bands of lymph, the symptoms and physical 
signs are those of pleurisy with retraction, combined with paroxysmal 
cough, profuse expectoration of offensive muco-purulent sputa, and the 
other phenomena which attend a case of pronounced cirrhosis of the lung. 

In the fully established disease we find the following signs : 

On account of the diminution in size of the affected lung, the chest-wall 
corresponding to the shrunken organ is retracted. The ribs are flattened 
over the seat of disease, and the respiratory movement is impaired or sup- 
pressed. If the lung is much reduced in size, the shoulder, the nipple, 
and the inferior angle of the scapula are lowered, the ribs are approxi- 
mated, and the circumference of the chest on that side is diminished to 
the measuring tape. An outline of the chest drawn from the cyrtometer 
shows this difference between the two sides very clearly. In addition a 
certain displacement of soft parts in the neighbourhood is to be noted. 
The mediastinum is drawn towards the affected side, and the opposite lung 
is found on percussion to project across the middle line of the chest. The 
heart is also displaced, unless adhesions between the pericardium and ad- 
joining pleura retain it in its normal position. If the upper part of the 
left lung be the seat of disease, the heart is drawn upwards. If the right 
lung be affected, the heart is pulled towards the right side, and in extreme 
cases may be felt beating to the right of the sternum. Vocal vibration is 
sometimes plainly perceptible over the indurated organ, although it is ab- 
sent from the sound side. In other cases no fremitus may be perceived 
over the affected half of the chest when the child speaks, although it can 
be felt over the healthy lung. The percussion-note is of wooden or tubular 
quality, and there is usually marked resistance of the chest-wall. This in- 
crease of resistance is especially noticeable when the diseased lung is the 
seat of an intercurrent attack of broncho-pneumonia ; and the percussion 
note at this time may be as completely dull and toneless as in cases of 
pleuritic effusion. The breath-sound is found to vary according to the 
amount of secretion retained in the tubes at the time of examination. If 
the dilated tubes are full of muco-pus, the breath-sound is weak and bron- 
chial, with little rhonchus ; and resonance of the voice when the child 
speaks is faint or suppressed. If the air-passages are comparatively empty, 
the respiration is loud and blowing, often intensely cavernous, or even 
amphoric, with metallic echo : and large, crisp, metallic bubbles, with dry, 
creaking sounds, are heard with both inspiration and expiration. These 
signs are in most cases limited to one-half of the chest. 

The symptoms noted in a case of pronounced cirrhosis are in part due 
to the condition of the lung itself ; but in part they are the consequence 
of the obstructed pulmonary circulation. 

The cough is a very characteristic symptom. Owing to retention of 
secretion in the dilated tubes, and to loss of elasticity in their indurated 
walls, cough is severe and spasmodic. It occurs at comparatively rare in- 
tervals, and consists in a rapid succession of loose-sounding hacks which 
often continue for many minutes. The child's face becomes congested 
and his eyelids suffused, and his whole body often shakes with the vio- 
lence of the paroxysm. After lasting a variable time the cough ends in 



FIBROID INDURATION OF THE LUNG— SYMPTOMS. 477 

spasmodic contractions of the diaphragm, and enormous quantities of 
offensive purulent matter are retched or expectorated. The unpleasant 
smell of the morbid secretion is due partly to its retention and consequent 
putrefaction in the dilated tubes, and partly to the presence in it of gan- 
grenous shreds of mucous membrane. The same causes communicate a 
fetor to the child's breath, which can be perceived at a considerable dis- 
tance from his cot. Sometimes the expectorated matters are tinged with 
blood ; but haemoptysis from this cause is not common in the child. 
Epistaxis may, however, occur, and the blood from the nose may be swal- 
lowed and retched up again at the end of a cough, so as to appear as if 
brought up from the lungs. . 

The respirations are usually from 30 to 35 in the minute. If broncho- 
pneumonia be superadded, the breathing becomes much more hurried, and 
the pulse-respiration ratio is perverted. 

The appetite is often good, and although the child is pale as a rule, his 
nutrition, as has been said, unless interfered with by an intercurrent in- 
flammatory attack, may be fairly satisfactory. During the attacks of ca- 
tarrhal pneumonia, however, he was'es rapidly ; and if the disease has 
produced marked contraction of the side, the child is usually greatly 
emaciated. 

Pyrexia is not a symptom of the uncomplicated disease. When pres- 
ent, it usually indicates the occurrence of bronchitis or pneumonia, and 
is then 102° or 103°, or even higher. A more moderate pyrexia may be 
the consequence of ulceration of the bronchial tubes. In these cases a 
microscopical examination of the sputum will discover the presence of 
fibres of elastic tissue. 

In addition to the above symptoms others are present which are the 
consequence of interference with the pulmonary circulation. The right 
side of the heart becomes hypertrophied, and the systemic venous system 
is fuller than natural, so that the veins of the neck and chest, and often of 
the limbs, are abnormally prominent. The fingers are clubbed, and in 
advanced cases there may be a congested, turgid appearance of the face. 

Amyloid disease of the liver, spleen, and kidneys is commonly present 
in advanced cases. If this be marked, there may be great anaemia and 
general dropsy. 

Although in most cases fibroid induration of the lung is accompanied 
by marked contraction of the side, this symptom is not always present. 
In one of the most pronounced examples of the disease which has come 
under my notice — a child of five years old — the chest was well-shaped, and 
the affected half, although slightly flattened posteriorly and at the junction 
of the lateral and anterior thirds, was little inferior to the healthy side in 
actual measurement. In this case dissection of the body showed that 
the shrinking and condensation of the lung tissue was compensated for by 
enormous dilatation of the air-tubes, so that the space occupied by the or- 
gan in the chest cavity was little diminished. Even if the lung be con- 
densed so as to reduce its volume much below the standard of health, 
marked contraction of the chest may be prevented by the drawing into 
the affected side of movable organs in the neighbourhood. Thus, in a boy 
— aged eleven years — in whom the shrunken right lung was reduced to a 
mere mass of gristle, the enlarged amyloid liver was drawn upwards so 
that its upper border was at the level of the third rib. This displacement 
prevented the chest from falling in, and the contraction of the side was 
limited to a little flattening under the clavicle. 

In cases where ulcerative destruction of lung ensues (fibroid phthisis) 



478 DISEASE IN CHILDREN. 

there is great interference with nutrition. The temperature is elevated, 
there is often hectic, and diarrhoea may occur with ulceration of the 
bowels. The symptoms are those common to the third stage of consump- 
tion, and the physical signs are such as have been described as accompany- 
ing confirmed pulmonary cirrhosis. In these cases the destructive process 
is soon followed by signs of deposit at the apex of the opposite lung. 

Fibroid induration does not always go en to fibroid phthisis. In 
children, at least, this is an exceptional mode of ending of the disease. 
As a rule the child succumbs to one of the intercurrent attacks of broncho- 
pneumonia, or falls a victim to a secondary acute tuberculosis. 

Diagnosis. — In the early stage of fibroid induration of the lung a certain 
diagnosis is impossible. We may suspect that the process is proceeding if 
a child be subject to repeated attacks of inflammation of the lung, and if 
after an unusually prolonged attack of catarrhal pneumonia the percussion- 
note remains high pitched, and the indications of dilatation of the bronchi 
are slow to subside ; but no positive opinion can be hazarded upon such 
insufficient data. 

The diagnosis of the confirmed disease rests upon the signs of shrink- 
ing and condensation of lung tissue combined with evidence of dilatation of 
the bronchi. There is great retraction of the affected side, indicated by 
falling in of the chest-wall, lowering of the shoulder, nipple, and inferior 
angle of the scapula, with curving of the spine — the concavity being 
towards the affected side. Neighbouring organs are displaced. . If the 
right lung be diseased, the liver is drawn upwards, the heart is felt beat- 
ing to the right of its normal position, and the resonance of the left lung 
passes across the middle line of the chest. If the left lung be contracted, 
the heart is drawn upwards and the right lung encroaches upon the left 
pleural cavity. 

On examination of the chest the percussion-note is wooden or tubular, 
with marked resistance, the breath-sound is weak or bronchial if the tubes 
contain much secretion, while after cough and expectoration loud blowing 
or cavernous breathing is heard, with large metallic bubbling rhonchus, 
and intense bronchophonic resonance of the voice. We find, also, indica- 
tions of interference with the pulmonary circulation. The right ventricle 
is hypertrophied ; the veins of the neck, chest, and arms are fuller than 
natural, and the fingers are clubbed. 

The violent paroxysmal cough ending in retching, and the discharge of 
a large quantity of offensive purulent mucus is very characteristic ; and 
this symptom, combined with the sudden change in the physical signs 
which is noticed at once when the dilated tubes have been relieved of their 
contents, is a strong argument in favour of fibroid induration. 

Pleurisy, with retraction of the side, presents physical signs very similar 
to the above. But in this case, although the breathing in the child is not 
unfrequently hollow, it is rarely cavernous, and is not accompanied by 
metallic gurgling. Moreover, the cough is not paroxysmal, and expectora- 
tion is scanty or absent. Cirrhosis of the lung may, however, follow upon 
long-standing pleurisy. It is detected by the gradual supervention of signs 
of bronchial dilatation with copious purulent sputa. 

If on account of extreme dilatation of the bronchi no retraction of the 
side is present, the characteristic cough, the profuse sputa, the sudden 
change in the physical signs after expectoration, and the history of repeated 
failure of health, with rapid improvement under favourable conditions of 
living, are symptoms of the utmost value. 

Ordinary pulmonary phthisis is usually combined with a certain degree 



FIBROID INDURATION OF THE LUNG— TREATMENT. 479 

of fibroid overgrowth. The distinction between dilated bronchi and cavi- 
ties due to ulcerative destruction of lung is elsewhere considered (see page 
514). In any case the strict limitation of the disease to one side of the 
chest is a strong argument in favour of the fibroid disease, for pulmonary 
phthisis in the third stage is never confined to one lung. It must be re- 
membered that cavities resulting from ulceration of lung may be combined 
with dilated bronchi (fibroid phthisis). In such a case the apex of the 
opposite lung is probably also the seat of disease. The diagnosis will then 
rest upon the history of the illness and the evidence of marked contraction. 

Prognosis. — Although fibroid induration of the lung usually tends to 
increase, the immediate prospects of the child are not unfavourable so long 
as the disease is limited in extent and remains uncomplicated. The danger 
of these cases arises from the secondary disturbances, which are a common 
and unfortunate consequence of this condition of the lung. A catarrh 
causes great increase of bronchial secretion, and often leads to retention 
and decomposition of purulent matter in the dilated tubes. The irritation 
thus induced may be sufficient by itself to set up a catarrhal pneumonia. 
Fortunately in these attacks the type of the intercurrent disease is usually 
subacute ; but its course is apt to be protracted, and if the fibroid consoli- 
dation is advanced, or the nutrition of the child impaired, the patient may 
succumb to the complication. 

The continuance of healthy nutrition is very necessary to the favour- 
able progress of these cases, and any derangement which tends to reduce 
the strength, such as digestive disturbance, vomiting, or diarrhoea, is dis- 
tinctly injurious. The progress is more favourable when the disease is 
seated at the upper part of the lung than when it occupies the base. In 
the first case, on account of the downward direction of the air-tubes, 
retention of secretion is less liable to occur ; in the second case the force 
of gravity helps to favour accumulation in the tubes. 

In the later stage of the illness, when amyloid disease of organs has 
occurred, the prognosis is serious ; but even at this period, if the patient be 
living in a climate which allows him to pass much of his time in the open 
air without risk of chill, nutrition may be carried on fairly well. (Edema 
with or without amyloid change is an unfavourable sign, as it indicates a 
a very unsatisfactory state of the blood. 

Treatment. — In the treatment of this chronic disease we can do nothing 
to remedy the mischief in the lung so far as it is already completed. 
Wherever the fibroid change has advanced, the tissue affected is injured 
beyond hope of repair, and no treatment can cause absorption of the mor- 
bid material in the lung. Still, we can do much by careful attention to 
the conditions of life of the child to prevent further spread of the disease. 
Our efforts must be directed to the removal of irritation in the lung, so as 
to arrest the tendency to active change, and to the promotion of healthy 
nutrition. The chief cause of the extension of the indurating process is 
the presence of bronchial secretion in the tubes. We must therefore do 
all in our power to avert the risk of chill ; and if a catarrh attack the lung, 
it must be treated without delay. The child must be dressed from head to 
foot in flannel or woollen underclothing, and should never leave the house 
in cold or damp weather without suitable covering to his neck and chest. 
This precaution is the more necessary as confinement to hot rooms is to be 
deprecated ; and if the child be properly protected from cold, regular exer- 
cise should be insisted upon. If practicable, it is desirable that the child 
should pass the winter in a dry and bracing, but equable climate, where 
he is not liable to suffer from constant changes of temperature. His diet 



480 DISEASE IN CHILDEEN. 

should be nutritious, consisting of meat, eggs, milk, etc., avoiding excess 
of farinaceous food ; and if he be weakly, half a glass of port wine, or of the 
St. Eaphael tannin wine, diluted with an equal quantity of water, may be 
given him with his dinner. Iron and cod-liver oil are always indicated in 
these cases. 

Directly signs of catarrh are noticed the child must be confined to his 
bed, and be subjected to the treatment recommended for such cases (see 
Bronchitis). 

In the more advanced stage of the disease much may be done by suit- 
able medication to relieve the more distressing symptoms. One of our 
first objects should be to control the amount of secretion and destroy its 
fetor. Astringent remedies given by the mouth and inhaled into the lungs 
are very useful for this purpose. The child should take quinine (gr. j.-ij.), 
with tinct. ferri perchloridi (n| x.-xx.) and a few drops of liq. morphine 
several times in the day ; and astringent and antiseptic solutions should be 
spra3^ed into the throat at suitable intervals. These solutions must not be 
too strong or they may excite so much cough that their use will have to 
be discontinued. Alum (gr. x. to the oz. of water) and tannin (half a grain 
to the oz.) are both very useful ; or we may use carbolic acid or creasote 
( TT|, xx. to the pint of hot water) combined with a drachm of tinct. benzoini 
co. as an inhalation. Turpentine given internally is often a valuable 
remedy in diminishing the amount of secretion. It may be administered 
in doses of ten or twenty drops every three or four hours. Keducing the 
quantity of fluid allowed for drink will often considerably diminish the 
secretion ; but children do not readily submit to this deprivation. 

Vomiting is useful, as the act helps to effect the discharge of secretion 
from the tubes ; but the paroxysms of cough are apt to be excited by 
taking food, and if the contents of the stomach are ejected shortly after a 
meal the loss of nourishment may cause serious interference with nutrition. 
In these cases it is advisable to give small doses of arsenic (tt[ j.-ij.) two or 
three times a day, or a drop or two of liq. strychnine, for both of these 
remedies tend to control the retching efforts at the end of a fit of cough- 
ing. But the vomiting should be excited at a more convenient time, as in 
the early morning, by a draught of warm water, mustard and water, or a 
grain of sulphate of copper. 

Cod-liver oil and tonics are of great service at all stages of the disease ; 
and if amyloid degeneration of organs has occurred, and there be anaemia, 
iron is especially indicated. Dropsy must be treated on a similar plan. 
Any complications which arise in the course of the disease must receive 
immediate attention ; for it is indispensable to maintain the healthy work- 
ing of the animal functions. Therefore indigestion, diarrhoea, etc., must 
be treated by diet and suitable remedies, as directed in the chapters 
treating of these subjects. 



CHAPTER IX. 

BRONCHITIS. 

Inflammation of the mucous membrane lining the air-tubes is a com- 
mon cause of death in infancy and childhood. The disease may be danger- 
ous not only in itself but through its tendency to be accompanied by 
collapse of the lung or to pass into broncho-pneumonia. In young infants 
death, when it occurs in bronchitis, is seldom due to the uncomplicated 
disease. It is usually to be ascribed to one of the consequences which 
have been referred to. In older children a simple bronchitis may prove 
fatal, but up to the age of five or six years the untoward result is commonly 
due to extension of the inflammation to the finest tubes and terminal alveoli. 

Bronchitis may be a mild complaint or an affection of the utmost 
gravity. When the disease attacks only the large tubes, it is usually of 
little consequence and can be readily cured by judicious treatment, 
although even in these cases, if the patient be a weakly infant, fatal col- 
lapse may occur very suddenly and unexpectedly. When the disease 
spreads to the smaller tubes (capillary bronchitis) the illness is a very 
serious one, and many of these cases prove fatal. 

Causation. — Bronchitis may arise from exposure to weather and to 
changes of temperature like other forms of catarrhal derangement. It 
may also be set up by irritants inhaled into the air-passages. Thus an 
escape of gas in the nursery is sometimes a cause of bronchial catarrh. 
During the pyrexia attendant upon dentition children are especially sensi- 
tive to the causes of pulmonary disorder, and very slight chills will give 
rise to bronchitis in such subjects. Some children are said always to " cut 
their teeth with a cough." In other words, their exceptional sensibility at 
this time to atmospheric influences makes them catch cold very readily. 

Damp and cold combined, especially where great variations of tempera- 
ture occur, are fruitful causes of catarrhal disorders ; and if in a climate 
where such conditions prevail the child is insufficiently clothed, he usually 
becomes a frequent sufferer from bronchial derangements. Some mothers 
have a curious dislike to flannel worn next to the skin, and accustom their 
children in all seasons to depend solely upon the warmth of their frocks 
and wrappers for protection against the cold. The common result of such 
a practice is to increase the natural susceptibility to chill ; and many a 
child's life has been sacrificed to this senseless prejudice. 

Besides the primary form of bronchitis which is induced by the above 
causes, the disease is frequently met with as a secondary affection. There 
are many forms of illness which are habitually complicated by pulmonary 
catarrh. Whooping-cough, measles, typhoid fever, and acute pulmonary 
tuberculosis are amongst the number. In others an intercurrent bronchi- 
tis is a frequent phenomenon. Thus in scarlatina, small-pox, diphtheria, 
certain special lung diseases, as croupous pneumonia and pleurisy, and 
31 



482 DISEASE IN CHILDEEN. 

in diseases of the heart and kidneys, bronchitis is a frequent complica- 
tion. 

Morbid Anatomy. — The anatomical changes induced by the disease in- 
volve primarily the mucous membrane, and may spread thence to deeper 
structures. The membrane is congested and consequently reddened and 
thickened. Sometimes it is softened. The secretion is at first diminished, 
but afterwards becomes copious and watery ; then thicker and more like 
pus. Under the microscope we find epithelial cells (many of them em- 
bryonic), granular cells, and pus corpuscles. 

When the bronchitis is capillary, the finer tubes are often found com- 
pletely occluded by this viscid muco-pus. This is especially the case in the 
lower lobes, into which the secretion has probably penetrated by inhalation 
and gravitation. More or less collapse is then usually found in the tissue 
with which the obstructed tubes are in connection. 

The inflammatory process is at first limited to the mucous membrane, 
but if the disease continues, may penetrate to the submucous tissue or 
even involve the whole thickness of the bronchial wall. In these cases dila- 
tation of the channel may take place, and acute enlargement (emphysema) 
of the air-cells may be found. Often the two opposite conditions of lob- 
ular collapse and lobular emphysema may be found side by side. 

Ulcerative excavations, described by Dr. Gairdner as "bronchial ab- 
scesses," sometimes occur. These are found in the centre of collapsed lob- 
ules, and consist of little collections of pus the size of a hemp-seed or 
larger. They communicate with the terminal tubes, and may be formed of 
dilatations of these tubes or of ulcerative destruction of the walls of ad- 
joining air-cells. In the former case they are lined by a fine villous mem- 
brane ; in the latter they are minute cavities in the lung substance, and 
their purulent contents he in immediate contact with the lung tissue. 
According to Dr. Gairdner, these purulent collections are the direct 
result of pus accumulated primarily in the extreme bronchial tubes of 
the collapsed lobules. The general appearance of these abscesses is 
that of softening tubercles, for which, indeed, they have been often mis- 
taken. 

In the majority of cases bronchitis is limited to the larger tubes, but 
even then the purulent secretion may be drawn inwards into the fine bron- 
chi ; and these are often found filled with viscid, yellow matter, even when 
their lining membrane is not inflamed. In young infants, who cannot 
cough at will, this retention is very liable to occur, and, as is elsewhere ex- 
plained, is one of the causes which render collapse of the lung so common 
a lesion in the beginning of life. 

Besides the anatomical characters which have been described, spots of 
catarrhal pneumonia are very common. The appearances resulting from 
this form of disease and the mode of its production are described elsewhere 
(see catarrhal pneumonia). 

In chronic bronchitis the mucous membrane often appears to be little 
affected, although sometimes it is smooth and polished. The smaller tubes 
are considerably dilated ; their transverse fibres are hypertrophied ; and 
the sub-mucous connective tissue is generally thickened. Considerable 
emphysema is usually met with, and collapse is an almost invariable feature 
of this form of the disease. 

Symptoms. — When the inflammation is confined to the larger bronchi, 
the symptoms are not severe unless the patient be a very young or weakly 
subject. In a new-born child or a feeble, wasted infant a slight degree of 
bronchial catarrh may be accompanied by very serious symptoms, and even 



BRONCHITIS — SYMPTOMS. 4S3 

lead to death from the occurrence of pulmonary collapse. This form of 
the disease is described elsewhere (see Collapse of the Lung). 

In stronger infants and older children the occurrence of catarrh of the 
larger bronchi is indicated by coryza and cough. The child sneezes and 
coughs at intervals. He complains of no pain, and if the cough is hard at 
the first it soon becomes loose, and ceases after a few days. In these mild 
cases the general symptoms are slight or wanting. There is no fever ; the 
child is lively and cheerful, and his appetite is little impaired. The tongue 
is usually furred, and there is some costiveness ; but an aperient powder 
soon remedies this inconvenience, and the child is quickly well. In such 
cases the only physical sign to be detected about the chest is the presence 
of a little sonoro-sibilant rhonchus or an occasional large bubble in the 
inter-scapular region. 

Although these cases are mild in themselves and easily cured, they may 
yet, by neglect, be so prolonged as to cause considerable interference with 
nutrition. If care be not taken to protect the patient from the ordinary 
causes of chill, he may pass through a succession of little colds, so that his 
cough continues for several weeks, and may be accompanied by a certain 
amount of catarrh of the stomach. Consequently, the child looks pale and 
gets flabby and languid. In such a state his condition may not only be 
considered an anxious one by his parents, who begin to entertain fears of 
consumption, but the resisting power of the child against changes of tem- 
perature being really lowered, he is very apt to alarm the practitioner by 
suddenly developing all the symptoms of acute broncho-pneumonia. 

If the catarrh assume a severe form, it often begins with fever and 
soreness behind the sternum. The temperature rises to 100 c or 101 c ; the 
tongue is thickly furred ; the pulse and respiration are both hurried, al- 
though their relation to one another is little altered ; and the bowels are 
confined. The nares act with respiration. The cough is at first hard and 
frequent and increases the pain in the chest. The skin is moist, the face 
flushed, and the child, if an infant, constantly requires to be in his nurse's 
arms. He is very thirsty, and on this account takes his bottle with eager- 
ness. A certain amount of gastrointestinal catarrh often accompanies the 
bronchitis. The child may vomit, and his bowels are often relaxed, Usu- 
ally, after a day or two the temperature subsides, the cough becomes 
looser, and the soreness of the chest abates. Under proper treatment, the 
child is usually well at the end of the week. 

The physical signs in these cases are of trifling amount. They consist 
merely in more or less large bubbling at each base, with dry rhonchus and 
occasional bubbling rales at various parts of the lungs. 

When the inflammation penetrates into the smaller tubes (capillary 
bronchitis) the symptoms become alarming. The features look pinched, 
and the expression is one of extreme distress. The face is pale, with much 
lividity about the eyelids and mouth. The child is restless. His dysp- 
noea is great, and his respiratory movements are laboured as well as hur- 
ried ; but if the disease is uncomplicated with collapse or lobular pneumo- 
nia, there is little disturbance of the normal proportion between the pulse 
and respiration. Often the child is subject to suffocative spasms if laid 
down, and has to be supported partially upright in his nurse's arms, or 
raised in his cot by pillows. At each inspiration considerable recession is 
noticed of the soft parts of the chest ; and if the ribs are yielding from 
rickets, the retraction of the bases of the chest may be extreme. The tem- 
perature at first is raised to 101° or 102°, but when aeration of the blood 
is greatly interfered with the mercury usually sinks to 99°. 



484 DISEASE IN CHILDEEN. 

The pulse rises to 140 or 150, or even higher, and is small and often 
hard. The cough is hacking and hoarse, and occurs in stifling paroxysms, 
greatly increasing the difficulty of breathing and intensifying the lividity 
of the face. The skin is moist and beads of sweat are often seen stand- 
ing upon the brows. The tongue is moist and thickly furred. Appetite 
is completely lost and the child is very thirsty. Still, on account of the 
dyspnoea an infant is quite unable to draw fluid from a bottle. The 
mouth is required as an air-passage, and the needs of respiration preclude 
its being used for any other purpose. Vomiting sometimes follows a par- 
oxysm of cough, and much whitish or yellowish phlegm is thrown up with 
the contents of the stomach. In this state the child rarely speaks or cries. 
Crying interferes with respiration, and he has no breath to spare. 

On examination of the chest percussion discovers no dulness. With 
the stethoscope the breath sounds are found to be more or less completely 
covered by a copious sub-crepitant rhonchus which is heard over both lungs. 
In an uncomplicated case the breathing is nowhere bronchial or blowing, 
and the resonance pi the voice is unaltered. These cases are, however, so 
often complicated w r ith atelectasis or broncho-pneumonia that the physical 
signs connected with these forms of disease are often to be detected at tho 
posterior bases. 

Unless an amelioration in the symptoms occurs suddenly, the distress 
becomes more and more marked.. The fits of dyspnoea are more frequent 
and alarming. The child, as long as his strength will allow, tosses in his 
bed, throwing his arms about restlessly. In an infant or rickety child the 
symptoms pass on to those which have been described as characteristic of 
atelectasis or of catarrhal pneumonia. In older children, in whom these 
complications are less likely to occur, the face assumes a leaden hue ; the 
fingers and nails grow purple ; the breathing is more hurried, and the pulse 
gets excessively rapid and small. As the weakness and asphyxia become 
more marked the cough ceases ; the restlessness diminishes ; the child be- 
comes drowsy and intensely apathetic, and soon dies comatose or con- 
vulsed. The temperature often sinks to a normal level when the symptoms 
of asphyxia become more pronounced, but often rises again before death 
to 102° or 103°. 

If the case terminate favourably, the eyes grow brighter and the livid- 
ity begins to clear ; the cough is looser and less paroxysmal ; the pulse 
slackens ; the breathing is less laboured ; and the child takes more notice, 
seeming to be less absorbed in his own uneasy sensations. 

The chronic form of bronchitis is not rare at the age of five or six 
years and upwards. It usually occurs in children of scrofulous tendencies 
who have been subject to repeated attacks of bronchial catarrh, and suffer 
in consequence from some permanent emphysema of the lungs. Such 
children are very sensitive to chills, and are apt to be troubled in the 
changeable seasons of the year with a distressing cough and shortness of 
>breath. Measles and pertussis in strumous subjects are often followed by 
the same pulmonary susceptibility, so that during the colder months the 
patients wheeze and cough, and present all the symptoms of chronic bron- 
chitis such as result from the same conditions in elderly persons. 

In the milder form of the disease the child merely suffers from a 
chronic cough, which undergoes very noticeable exacerbations on any 
change of the weather, and on the occurrence of a chill is complicated for 
a time by the symptoms of an acute attack of pulmonary catarrh. These 
cases often' give much trouble and are very difficult of cure. 

In a severer form, when the emphysema is marked, the chest becomes 



BRONCHITIS — SYMPTOMS — DIAGNOSIS. 485 

barrel-slmped ; the shin is habitually dry and the fingers are slightly 
clubbed. These children are almost invariably short and thick-set, with 
coarse features, thick turgid lips, broad shoulders, and large bones. They 
often stoop as they walk. During the summer months they are fairly well, 
with a good appetite ; and although they may pant after exertion, do not 
suffer from noticeable shortness of breath. In the winter they have a per- 
sistent cough, and cannot indulge in noisy games, as much movement pro- 
duces instant dyspnoea. The cough is loose and paroxysmal ; sometimes 
they expectorate frothy, yellow phlegm. The face is usually livid and 
puffy-looking. The appetite is capricious, and vomiting is frequent after 
cough. The bowels are costive. 

On examination of the chest we find general hyper-resonance ; and the 
respiratory sounds are more or less concealed by a fine crackling rhonchus. 
If, as often happens, there is dilatation of the bronchi, the respiration in the 
inter-scapular region may be bronchial or even cavernous. As a rule the 
temperature is normal. 

Chronic catarrh of the stomach or bowels, or both, often occurs in these 
cases. The appetite is poor ; the bowels are loose and contain much 
mucus ; and the loss of flesh is rapid. With great care the pulmonary 
catarrh may be kept under, and if the child's strength be properly sup- 
ported, life may be prolonged until the return of more genial weather, when 
the patient very quickly begins to improve. In too many cases, however, 
death ensues as a consequence of an intercurrent attack in which the tem- 
perature rises, and the symptoms which have been described as the conse- 
quence of capillary bronchitis are noticed. 

A boy, aged thirteen years, both of whose parents were said to be " weak 
in the chest," was healthy up to the age of eight years, when he had an 
attack of measles followed by pertussis. From that time he suffered from 
cough which was always worse in the winter. He was admitted into the 
Victoria Park Hospital in February for a severe bronchitis. 

The boy was fairly nourished and well built, although short for his age. 
His chest was full and expanded above, but at the lower part on each side 
there was some infra-mammary depression. The spine was straight. The 
heart's apex was in the fifth interspace, three quarters of an inch to the 
inner side of the nipple line. Its impulse could be also felt in the epigas- 
trium. The skin was dry and harsh ; the fingers were slightly clubbed ; 
the liver and spleen seemed pushed downwards. The face was congested, 
turgid, and more or less livid. The breathing was laboured, and the boy 
could not lie down in his bed. The temperature was normal and the 
urine healthy. 

On examination of the chest the percussion note generally was hyper- 
resonant ; and everywhere over the chest the breath sounds were concealed 
by a copious, fine, crackling rhonchus. This at the base was very super- 
ficial and ringing. The boy remained in the hospital until June, being 
sometimes better, sometimes worse ; and the amount of rhonchus varied 
considerably from time to time. The temperature rarely rose above 99°. 
On his discharge, although his breathing was much better and his general 
condition fairly good, much rhonchus remained at the bases of the lungs. 

Diagnosis. — There is little difficulty about the diagnosis of bronchitis. 
In the milder form a mistake is hardly possible unless from teething or 
other cause there is a high degree of fever. With considerable pyrexia 
the derangement may be mistaken for measles or broncho-pneumonia. 
In the first case the occurrence of the characteristic rash on the fourth day 
will clear up the difficulty. In the second, the absence of distress in the 



486 DISEASE IN CHILDREN. 

face, the normal pulse-respiration ratio, and the limited amount of rhon- 
chus detected by the ear will furnish a sufficient distinction. 

In capillary bronchitis the laboured breathing, the thick and often 
paroxysmal cough, the copious mucous rales heard with the stethoscope, 
combined with the absence of dulness on percussion and of bronchial or 
blowing breathing, are sufficiently distinctive. A point of great importance 
is the exclusion of atelectasis and of catarrhal pneumonia. The new feat- 
ures introduced into the case by the occurrence of either of these complica- 
tions are referred to elsewhere (see pages 467 and 436 ). 

Prognosis. — As long as the catarrh remains limited to the larger tubes 
the prognosis depends upon the age and general strength of the patient. 
However slight the disorder may be, we can never feel sure that in a new- 
born, a weakly, or a rickety infant fatal collapse of the lung may not follow 
unexpectedly. In all such cases, therefore, we should warn the parents of 
this possible danger, and caution them to watch carefully for lividity, 
drowsiness, or other sign indicating insufficient aeration of the blood. 

In capillary bronchitis the danger is great, however healthy the child 
may have previously been ; and if the patient be weakly or the subject of 
rickets, the peril is really urgent. Indeed, few such cases recover. The ex- 
tremity of the danger is indicated by a high degree of interference with 
the aeration of the blood. If the child become intensely apathetic or irre- 
sistibly drowsy, with blueness of finger-ends, an ashy-gray face, dull and 
lustreless eyes, and a normal or sub-normal temperature, death can scarcely 
be avoided. Other signs of unfavourable import are suppression of the 
cough, great rapidity of the pulse and respiration, smallness of pulse and 
fulness of superficial veins, with retraction of the base of the chest in in- 
spiration. 

Signs indicative of collapse of the lung or of broncho-pneumonia augur 
ill for the child's chances of recovery. 

Treatment. — A pulmonary catarrh in a child, especially if the patient be 
weakly or of a rickety constitution, should never be treated lightly. In the 
mildest case the patient should be kept in his room and be made to take a 
saline mixture containing a few drops of ipeca.cuanha or antimonial wine 
in each dose. If there is any rise of temperature, he should be at once 
put to bed. This is essential. Perfect quiet is necessary for a feverish 
child ; and even if pyrexia be absent, the repose and equable temperature 
of his cot will hasten the patient's recovery more certainly than the most 
energetic medication. Indeed, without this precaution treatment loses more 
than half its value. In the next place we must employ counter-irritation. 
There is, however, a right and a wrong way even of using a poultice. 
Weak applications in these cases are better than strong irritants ; for a far 
more effectual impression is made by acting slowly upon a large surface 
of the skin, than by producing a more violent irritation of a comparatively 
limited area. One part of mustard should be diluted with five or six times 
its bulk of finely ground linseed meal. The ingredients should be care- 
fully mixed in the dry state and made into a poultice with hot but not 
boiling water. The application should be sufficiently large to cover the 
whole front of the chest, and should be allowed to remain in contact with 
the skin for six or eight hours, or even longer if the child can bear it. A 
layer of cotton wool should be then applied in its place, and a fresh poul- 
tice of similar strength should be made for the back and be kept on for an 
equal period of time. An infant will bear this strength well. For an 
older child a larger proportion of mustard may be used ; but it is seldom 
wise to employ an application which cannot be borne for at least six hours. 



BRONCHITIS — TREATMENT. 487 

The effect of these measures is seen very quickly. In the milder forms of 
the disease the hard cough becomes soft and loose, the soreness of the 
chest subsides, and the pyrexia quickly disappears. Even in the more 
severe variety a sensible diminution in the distress and the labour of 
breathing is usually manifested when the skin becomes very red from the 
action of the irritant. 

The diet should consist of milk and broth ; and the child should be 
allowed to drink freely of thin barley-water. 

For medicine, a grain of calomel should be given in a little sugar, and 
be followed after a few hours by a dose of castor-oil or other mild aperi- 
ent. A febrifuge mixture can then be prescribed, such as citrate of potash 
or the solution of acetate of ammonia with a few drops of ijjecacuanha or 
antimonial wine. A pleasant form in which these can be given is the fol- 
lowing : — 

fy . Vini ipecacuanha TT[ v. 

Liq. ammonise acetatis HI x. 

Glycerini TT[ xv. 

Aquam florae aurantii ad 3 j. 

M. Ft. haustus. 

Sig. To be taken every four hours. 

The above is suitable to an infant. For older children the proportions 
may be increased, or the draught can be given more frequently. 

Unless the bronchitis be severe, the bronchial derangement quickly 
yields to this treatment and the patient is soon convalescent. If the cough 
continue after it has become loose, and the child's appetite has returned, a 
few drops of paregoric and tincture of squill added to the mixture will 
soon effect its removal. Stimulating expectorants are as useful at the 
later stage of the catarrh, after the cough has become loose and easy, as 
they are injurious at an earlier period when it is hard and painful. 

In capillary bronchitis the child should wear a flannel night-dress, and 
the temperature of his room should be kept at 70° or 75°. It is also ad- 
visable to moisten the air round his cot by vapour from one of the many 
varieties of bronchitis kettle, or by Dr. R. J. Lee's "steam-draught inhaler." 
The poulticing of the chest should be carried out energetically ; and when 
the skin can no longer bear the irritant, the chest should be wrapped in 
cotton wool. 

In this severe form of the disease stimulant expectorants are not only 
useless as remedial agents, but tend directly to increase the congestion 
and irritation of the mucous membrane. However feeble the child may 
be, if the cough is hard and the chest tight, ammonia, squill, tolu, and other 
remedies which exercise a stimulating effect upon the mucous membrane 
should be avoided. In such cases the distress of the patient is most cer- 
tainly relieved and his strength improved by medicines, such as salines 
with ipecacuanha, which promote free secretion from the tubes. If neces- 
sary, this treatment can be supplemented by general stimulants, such as 
alcohol ; and in weakly children it is very necessary to counteract any de- 
pressing effect of the remedies upon the system by the free administration 
of brandy-and-egg. In young children whose strength is good it is often 
useful at the earlier periods of the disease, when the cough is hard and 
much soreness is complained of in the chest, to give two or three grains of 
powdered ipecacuanha in a teaspoonful of mucilage twice a day on an 
empty stomach. The emetic in these small doses excites vomiting with 



488 DISEASE IN CHILDBED. 

very little effort, and causes the expulsion of much mucus from the stomach 
and lungs. After a few doses of this remedy the character of the cough 
often undergoes a marked change for the better, and the distress of the 
patient is greatly relieved. So long, therefore, as there is fever with hard 
cough, tightness behind the sternum, and lividity of the face, we should 
confine ourselves to ipecacuanha or antimonial wines (TT[ v.-x.), citrate of 
potash (gr. iij.-v.), solution of acetate of ammonia (Tit x.-xxx.), spirits of 
nitrous ether (TT[ x.-xxx.), and similar remedies. 

Although the medicines recommended are all such as aid the free secre- 
tion of mucus, they are not given with any object of producing depression. 
On the contrary, we should watch the patient carefully for signs of prostra- 
tion, and hold ourselves in readiness to correct any undue sedative influence 
by alcoholic stimulation. We must not, however, be in a hurry to give wine 
or brandy. A small feeble pulse will be often found to become fuller and 
stronger as secretion from the inflamed mucous membrane becomes more 
copious and the congestion of the pulmonary vessels declines. 

In children of four or five years old and upwards a grain of calomel with 
two or three grains of jalapine at the beginning of the treatment is always 
useful. It is unnecessary to keep up a free action of the bowels, for these 
cases appear to be little benefited by purging ; but a thorough unloading 
of the liver is very useful as a preliminary measure. Even in infants half 
a grain of calomel followed by a teaspoonful of castor oil often seems to 
render the after-course of the disease milder and more tractable. 

The above method of treatment will usually be found successful in cases 
of primary capillary bronchitis, when the patient is seen before collapse of 
the lung has occurred or the disease has passed into a chronic broncho- 
pneumonia. It is important that we should not allow ourselves to be 
tempted, by the apparent prostration of the patient, to prescribe ammonia 
and other stimulating drugs. When the pulmonary vessels are congested 
and the obstruction to the circulation is extreme, the heart labours, the 
face is livid, and the pulse is small and feeble ; but these symptoms con- 
stitute no real indication for ammonia. We shall best relieve the impedi- 
ment to the pulmonary circulation and promote the aeration of the blood 
by measures which relieve the congestion by producing free secretion from 
the overloaded vessels. 

Opium should not be given unless the restlessness is great, and even 
then the remedy is hardly a judicious one ; for anything which dulls the 
sensibility of the bronchial mucous membrane hinders the expulsion of 
the phlegm and favours collapse of the air-cells. Aconite, veratrum viride, 
and other powerful cardiac sedatives are only admissible during the first 
forty-eight hours, and must on no account be given to young infants. 

In capillary bronchitis, as in the case of the milder forms of the dis- 
ease, when the cough is quite loose and secretion free, small doses of 
morphia or paregoric, with ammonia and infusion of senega or serpentaria, 
will soon bring the disease to a favourable ending. Profuseness of secre- 
tion at a late stage of the illness is an indication for small doses of iron. 
In infants, perhaps a few drops of sal volatile make the better remedy ; 
but after this age the administration of four or five grains of the citrate of 
iron with a drop or two of liq. morphise, and a few grains of the bi-carbon- 
ate of soda, is attended with great benefit. So, also, a grain of quinine 
with a couple of drops of dilute nitric acid, and the same quantity of laud- 
anum or solution of morphia, given several times in the day, will soon 
brace up the relaxed mucous membrane and diminish the frequency of the 
cough. These remedies must of course be confined to the later stage of 



BRONCHITIS— TEEATMEXT. 489 

the disease, after the pyrexia lias subsided, and when secretion is copious 
from want of tone. 

In all forms of bronchial catarrh in weakly infants or rickety children 
the patient should be carefully watched for signs of collapse of the lung. 
If we notice the child suddenly to become drowsy, and find that this change 
is associated with lividity of the face, very rapid and shallow breathing, 
and a fall of temperature to a sub-normal level, energetic measures should 
be taken to promote re-expansion of the collapsed lobules (see Atelectasis). 

A secondary bronchitis, such as that which is apt to occur in the sub- 
jects of rickets, must be treated upon the same principles ; but in these 
cases alcoholic stimulation is usually required early. 

In chronic bronchitis the child should, if possible, be sent away for the 
winter to a mild climate where he can pass his time out of doors without 
risk of chill. A sea voyage is very beneficial to these patients. As this 
form of the disease usually occurs in scrofulous children, the general treat- 
ment which has been recommended for that constitutional condition should 
be put in force. 

The intercurrent acute attacks must be treated upon the principles 
which have been already indicated. Still, after the disease has returned to its 
ordinary chronic course expectoration is often very difficult, and the breath- 
ing oppressed ; and with the stethoscope we hear much large bubbling at 
the bases and for a considerable distance over both lungs. In these cases 
the ordinary expectorants seem to exercise little influence unless combined 
with tonics. Quinine or quinine and iron, given with tincture of squill, 
ipecacuanha, and a drop or two of solution of morphia will often be found 
successful in relieving the symptoms. Cod-liver oil is also of great value not 
only in improving the general health, but also in checking secretion and 
promoting the expulsion of phlegm. Tar taken internally has sometimes 
a marked influence in checking secretion and giving a more healthy tone to 
the mucous membrane. A drop of liquid tar may be given on a small 
lump of sugar two or three times in the day ; or for children who can take 
pills the remedy may be given as follows : 

r> . Picis liquids? gx*. ij - 

Lycopodii gr. j. 

Pulv. glycyrrhizse gr. ss. 

Glycerini q. s. 

M. Ft. pilula. 

Sig. To be taken three or four times a day. 

Inhalations are of service in these cases. The vapour of hot water im- 
pregnated with creasote, carbolic acid, or tincture of iodine (of either 
twenty drops to the pint), or of oil of turpentine (one drachm to the pint), 
can be inhaled for half an hour several times in the day from Dr. R. J. 
Lee's " steam-draught inhaler." 

The hypodermic injection of pilocarpine is often useful. In the case 
of the boy referred to above, one-fifteenth of a grain of the hydrochlorate 
of pilocarpine was injected under the skin twice a day. The remedy 
caused copious sweating, and produced vomiting by which much mucus 
was expelled from the lungs. The effect of the drug was decided in 
diminishing for a time the amount of secretion, although it produced 
little permanent impression upon the disease. 

Counter-irritation of the chest with the tincture or liniment of iodine 



490 DISEASE IN CHILDREN. 

is often attended with great benefit ; and warm woollen clothing worn 
next to the skin is essential to improvement. Still, in spite of all our 
efforts, although the child may appear better for the time, a cure is hardly 
possible in pronounced cases so long as the patient remains in a cold, 
damp climate. His only hope of throwing off the disease lies in his 
removal to a suitable air where he is not exposed to the constant risk of 
chill, and where no untoward conditions are present to interfere with his 
favourable progress. 



CHAPTEK X. 

EMPHYSEMA. 

Pulmonaey emphysema is not uncommon in the child. As an acute 
lesion it is of frequent occurrence, arising in the course of various forms 
of pulmonary disease. It is then of little consequence, is accompanied by 
few symptoms, and usually subsides when the primary complaint has 
disappeared. As a chronic affection emphysema is met with much more 
rarely in early life ; but a child so afflicted presents all the symptoms 
common to the adult sufferer, and may have his health permanently in- 
jured and his life considerably shortened by this condition of his lung. 
The lesion may be seen both in the vesicular and interlobular forms, and 
has been found at all periods of childhood, even in new born infants. 

Causation. — Pulmonary emphysema is always a secondary disease, and 
appears to be mainly due to forcible distention of the air-cells in the act 
of coughing. It is found in various forms of lung disease, especially in 
whooping-cough, bronchitis, and catarrhal pneumonia. Of these the vio- 
lent cough of pertussis and catarrhal pneumonia produce the lesion with 
the greatest certainty, and emphysema is a constant complication of every 
severe attack of these two diseases. 

It seems probable that over-distention of the air-cells in these cases 
may be effected both by inspiratory and expiratory mechanism. In 
whooping-cough and bronchitis many air-vesicles are rendered impervious 
by patches of disseminated collapse. In lobular pneumonia considerable 
portions of lung may be closed to the entrance of air. In all these cases 
the diminution in the respiratory surface necessitates increased energy of 
inspiratory movement, so that the air-vesicles which remain pervious are 
over-distended. Again, a serious strain upon the air-cells is induced by 
strong expiratory efforts made when the glottis is closed, as when the 
patient is preparing to cough. Such efforts drive the air into the parts of 
the lungs which are the least supported, and dilate to excess the alveoli 
in these situations. In pertussis, especially, where the child strives with 
all his might to repress the cough, the strain is often very severe and long- 
continued. Marked emphysema of the apices and anterior margins of the 
lungs may be excited by this means, and if the over-stretched walls of the 
air-cells have been injured by the distention, the lesion may be a per- 
manent one. Usually the alveoli return to their normal size when their 
walls cease to be distended. It is only when the dilatation has been 
carried to an extreme degree, so as to impair the elasticity of the alveolar 
parietes, that the distention continues as a permanent condition. 

Besides the diseases which have been mentioned, any complaint of 
which cough is a symptom may give rise to emphysema ; as phthisis, 
where the alveoli at the bases often become distended ; pleurisy, where the 
air-vesicles of the sound lung are often temporarily over-dilated ; also 
stridulous laryngitis, if prolonged, and membranous croup. In advanced 



492 DISEASE IN CHILDREN. 

rickets, where there is marked grooving of the sides of the chest, the 
sternum is forced forwards at each inspiration, and the anterior borders of 
the lungs become over-distended with air. The mechanism of this form 
of emplrysema is referred to elsewhere (see page 134). The tendency to 
perpetuation of the vesicular dilatation appears to be influenced by the 
scrofulous diathesis. It may be that in that constitutional condition the 
elasticity of the alveolar walls is more readily impaired ; or it may be that 
the susceptibility to catarrh of the pulmonary membrane and other mucous 
tracts, inseparable from the strumous habit, induces a more frequent and 
persistent strain upon the air-cells. In any case the subjects of chronic 
emphysema in early life are usually found to be well-marked examples of 
the scrofulous diathesis. 

Pulmonary emphysema may be found at all ages. It is not uncommon 
even in infants recently born. Thus, out of thirty-seven cases collected 
by Hervieux, nineteen occurred in infants under twenty days old, and of 
these one had lived no longer than two days. So, in a child who died of 
tetanus under my care in the East London Children's Hospital, aged fifty 
hours, the lungs after death were found to be emphysematous along the 
anterior margins, and also in spots over the surface. There were some 
solid patches of unexpanded tissue in each lower lobe. 

Morbid Anatomy. — Pulmonary emphysema may be of the interlobular 
or vesicular variety. 

In interlobular emphysema the air occupies the connective tissue lying 
between the lobules and under the pleura. When infiltrated into the 
tissue between the lobules, air collects in small bubbles like little beads. 
When in the sub-pleural tissue, it forms blebs of varying size — sometimes 
isolated, when they may reach the size of a small nut ; sometimes arranged 
in lines, when they are rarely larger than an ear of wheat. Their shape is 
elongated or spherical. When thus extravasated into the pulmonary con- 
nective tissue, the air has been known to make its way into the anterior 
or posterior mediastinum and thence into the sub-cutaneous tissue of the 
face and neck. Thus, in a case published in 1834 by Dr. Bird Herapath — 
a child eighteen months old who had died of bronchitis secondary to 
whooping-cough — air was found to have escaped from one of the lobules 
seated at the root of the right lung into the anterior mediastinum. Start- 
ing from this point the air, without entering the pleura, had escaped along 
the sub-pleural connective tissue and formed numerous emphysematous 
swellings on the lung. It had distended the areolar tissue of the anterior 
mediastinum, and passing upwards had infiltrated into the cellular tissue 
of the neck, beneath the deeper cervical fascia and the subcutaneous 
tissue of the neck and chest. A similar case, in a child four months old, 
has been recorded by Dr. Pepper, of Philadelphia. In rare cases pneumo- 
thorax has been produced by rupture of the pleura and escape of air 
into the pleural cavity. 

Interlobular emphysema is almost always produced by rupture of an 
air-vesicle during a violent fit of coughing. It may, however, be the result 
of injury from without. 

In vesicular emphysema the apices and anterior borders of the lungs are 
the parts commonly affected. These portions are dull white in colour, 
dry, and bloodless. They convey to the finger a peculiar soft sensation, 
which Hervieux has compared to that noticed when pressing a piece of 
wadding covered with satin. Close inspection in a good light shows a 
multitude of little, bright, transparent points the size of a pin's head. 
Sometimes rather larger projections are visible, and these are often angular. 



EMPHYSEMA—SYMPTOMS. 493 

When the chest is opened in these cases the lungs remain distended, and 
their anterior borders are usually in contact so as to hide the greater por- 
tion of the cardiac surface. 

Symptoms. — Interlobular emphysema, unless the air spread through the 
mediastinum to the sub-cutaneous tissue of the neck and chest, gives rise 
to no symptoms. Its existence is only discovered on post-mortem examina- 
tion of the body. 

Even in the vesicular variety the limited amount of emphysema which 
is found when the disease is acute, as in cases of catarrhal pneumonia, or 
acute bronchitis with collapse, gives little evidence of its presence. Our 
knowledge of the morbid anatomy of such cases enables us to infer its ex- 
istence, but the occurrence of abnormal dilatation of the air-cells gives rise 
to no additional symptoms, and produces no characteristic modification of 
the physical signs. 

It is in the chronic form of the disease that we are able positively to 
determine the existence of over-distention of the pulmonary alveoli. In a 
pronounced case of emphysema the symptoms and physical signs are those 
familiar to us as a consequence of a similar condition in the adult. Such 
children, as has been already remarked, almost always present the char- 
acteristic features of the strumous constitution. The patient is usually 
short for his age and of sturdy build. His head is rather large, his neck 
short with prominent jugular veins, and his face pallid with a blueish tint 
round the mouth and eyes. The chest is flattened laterally at the base, 
and the lower part of the sternum is somewhat projecting. Consequently, 
its antero-posterior diameter is increased. The intercostal spaces are 
obliterated, and in rare cases slight bulging may be noticed above the 
clavicles. Sometimes the back is a little rounded, but I have never noticed 
the stoop of the shoulders, which is such a marked feature in the adult, 
unless the emphysema were combined with a persistent chronic bronchitis. 
The heart is pushed down so as to be felt beating in the epigastrium, and 
the liver and spleen are often appreciably displaced. 

"When a deep breath is taken the chest-walls rise and the shoulders are 
elevated ; but there is little expansion of the upper part of the thorax, and 
the constriction at the base is exaggerated. On percussion, general hyper- 
resonance is found in the front of the chest and the cardiac area of dulness 
is lessened. With the stethoscope we find that the breath sounds are loud 
and wheezing above, weak although very harsh below, and more or less 
sonoro-sibilant rhonchus is heard at various parts of the chest. 

The symptoms vary according to the condition of the pulmonary mucous 
membrane ; for, with such a state of lung, the child is excessively sus- 
ceptible to fresh catarrh. At his best his breathing is habitually short and 
oppressed, but he coughs little and his appetite and spirits may be good. 
It is when a new catarrh comes on that his troubles begin. When this ac- 
cident happens, the breathing at once becomes difficult and wheezing, and 
he is subject to attacks of dyspnoea which appear sometimes to be of the 
nature of asthmatic seizures. There is, however, another cause for these 
attacks. In scrofulous subjects the bronchial glands of the mediastina and 
lungs are apt to enlarge as a result of pulmonary irritation ; and these by 
their pressure upon the vagus, or directly upon the air-tubes, may produce 
serious impediment to the entrance of air. The child's cough is husky 
and often occurs in paroxysms. He cannot lie down in his bed, and is 
much troubled at night by cough and dyspnoea. If these symptoms con- 
tinue, the patient passes into the condition which is described elsewhere 
under the name of chronic bronchitis, and a case is there narrated in which 



494 DISEASE IN CHILDREN. 

chronic pulmonary catarrh was associated with permanent emphysema of 
the lungs. 

In cases where the attacks of catarrh are only occasional and pass com- 
pletely away, the habitual state of the child is not unsatisfactory ; but he 
is liable at any moment to be laid by under the influence of a fresh chill. 

I may cite as a good example of chronic pulmonary emphysema the 
case of a little boy, aged three years, stout and thick-set, with large ends 
to his bones. The child only finished cutting his teeth at the age of two 
years and nine months, and was no doubt slightly rickety. He was said to 
have been wheezing off and on for eighteen months. Ten months pre- 
viously, he had been ill for a month with a severe attack of bronchitis, and 
had since that time been a constant sufferer from wheezing and short- 
ness of breath. In this boy the upper part of the chest was full and 
rounded, and there was some considerable constriction at the base. The 
heart's apex could be seen and felt in the epigastrium and between that 
point and the left nipple. The percussion note was drum-like all over the 
front of the chest, and much whistling and snoring rhonchus was heard 
over both lungs. The heart-sounds were healthy. 

Another little boy, aged two years and nine months, was said to have 
had a cough all his life, although it was better in the summer than the 
winter, and might even cease altogether for about six weeks in the warmest 
weather. The child was twelve months old before he cut his first tooth, 
and did not walk until the end of his second year. The ends of his long 
bones were full ; but his limbs were straight, and he was not a marked 
specimen of rickets. The breathing was not much oppressed ; the cough 
was hoarse, and the voice husky. He was not subject to attacks of dis- 
tressing dyspnoea, and was said never to have lost his voice. This little 
lad's chest was perceptibly retracted in the infra-mammary regions, and 
the lower part of the breast-bone projected. The spine was straight and 
the back rather flattened between the scapulae. At each breath there was 
a slight sinking of the epigastrium. On percussion there was general 
hyper-resonance of the front of the chest, especially along the sternum. 
Some sibilant and large bubbling rhonchi were heard at each base behind. 

In such cases as the above the emphysema is no doubt kept up by the 
repeated attacks of pulmonary catarrh. It is possible that if by residence 
in a suitable climate such intercurrent attacks could be prevented, the 
emphysema might subside and the lungs return to a normal condition ; 
but upon this point I cannot speak with certainty. 

It is not often in the child that serious secondary effects, such as 
passive congestion of the liver and kidneys, dilated hypertrophy of the right 
heart, oedema, etc., are noticed, although in some cases I have thought 
that the right ventricle was larger than natural. The danger of the disease 
consists principally in the repeated attacks of bronchitis from which these 
patients almost invariably suffer, and in the tendency of such attacks, if 
not immediately fatal, to run a chronic course. Usually, sooner or later, 
the life of the patient is brought prematurely to a close by this means. 

Diagnosis. — In the acute form of emphysema there are no symptoms 
sufficiently distinctive to indicate with certainty the presence of the lesion. 
This, however, is of little consequence, for no special treatment is required. 
In the large majority of cases the dilated air-cells return to their natural 
size when the cause or causes which have induced the distention are no 
longer in operation. 

In chronic emphysema the chest distended in the upper regions and 
hyper-resonant on percussion, the diminished area of cardiac dulness, the 



EMPHYSEMA — DIAGNOSIS — PROGNOSIS — TREATMENT. 495 

pulsation at the epigastrium, the displacement of the liver and spleen (if 
present), and the wheezing breath-sounds are sufficiently characteristic of 
the lesion. 

Prognosis. — In chronic emphysema the prognosis is not favourable ; 
for although the disease in itself is little hurtful to life, the accompanying 
tendency to catarrh is a serious danger to the patient. If the child be 
found to suffer from repeated attacks of bronchitis, and in the intervals 
to be wheezy and scant of breath, we can never feel satisfied with his 
condition or at ease with regard to his future prospects. 

In cases of interlobular emphysema, where this has led to infiltration 
of air into the subcutaneous tissue of the neck and chest, the prognosis 
depends chiefly upon the disease, in the course of which the complication 
has arisen. The presence of subcutaneous emphysema is probably of 
little consequence, for the infiltrated air usually becomes absorbed very 
quickly. 

Treatment — In cases where acute emphysema is suspected no special 
treatment is required. So, also, in interlobular emphysema, where this 
has made itself evident by the passage of air into the subcutaneous tissue, 
no special measures are needed to hasten the absorption of the infiltrated 
gases. They may safely be left to disperse at leisure. 

In chronic emphysema any existing bronchitis should receive immediate 
attention, and the treatment must be conducted upon the principles 
described elsewhere (see Bronchitis). In the attacks of acute dyspnoea 
emetics are very useful ; and ipecacuanha wine or the turpeth mineral, 
each of which produces free secretion of mucus, are to be preferred for 
this purpose. A teaspoonful of the former, or three or four grains of the 
latter in syrup, may be given every fifteen minutes until an effect is pro- 
duced. If the attacks continue, the feet should be soaked in a hot mustard 
foot-bath, mustard poultices should be applied to the chest and back, 
and a draught containing ether and the tincture of lobelia may be given 
every hour. Children bear lobelia well. Ten drops of the ethereal tinct- 
ure may be given to a child of two years old every hour or half hour 
without any danger. In very severe cases the fumes of Himrod's powder 
may be inhaled. When the bronchitis has subsided iron should be given. 
A good form for its administration is the tartarate of iron with iodide of 
potassium. The combination makes a perfectly clear mixture with dis- 
tilled water. It may be sweetened with glycerine. 

The food of the child should be nutritious and digestible. The diet 
should be regulated upon the principles already laid down for the treat- 
ment of scrofula. In fact, emphysematous subjects, who, as has been said, 
are very often of the strumous habit, require in all points such general 
treatment as is recommended elsewhere for children suffering from the 
scrofulous cachexia. The most important point in the treatment of pul- 
monary emphysema lies in the adoption of means for the prevention 
of catarrh. With this object we should urge upon the child's parents the 
necessity of removing the patient to an equable climate where he can live 
an out-door life without danger of chill. It is only by keeping the lungs 
free from catarrh that we can hope to promote a return of the air-cells to 
their normal condition. 






CHAPTER XL 

GANGRENE OF THE LUNG. 

Gangrene of the lung is not a common disease of childhood. If the num- 
ber of recorded cases be a fair measure of the relative frequency of the 
lesion, this form of illness would appear to be much more often met with 
in adult life than at an earlier age. A contrary opinion has, however, pre- 
vailed, chiefly on the authority of E. Boudet, who in the space of five 
months met with five cases of pulmonary gangrene in the child. This 
experience is, however, too exceptional to furnish a satisfactory base for 
statistical calculation. 

The extent of tissue which undergoes the gangrenous change is variable. 
The lesion may occupy only a limited patch in one of the lobes (circum- 
scribed gangrene), or may involve the whole of the lobe, or even of the 
lung (diffused gangrene). 

Causation. — Pulmonary gangrene may be the consequence of a general 
condition affecting the whole body, or may arise in constitutionally healthy 
subjects from some local cause which interferes with the circulation of the 
blood in the lung. 

In the first case, a disposition to spontaneous mortification of tissue is 
manifested as a result of the eruptive fevers, especially measles, and other 
depressing diseases which cause great prostration of nervous power and 
lower the nutrition of the whole body. The gangrene is usually of the 
diffused variety, and the lung is often not the only organ which suffers 
from the morbid tendency. There may be also gangrene of the gums, the 
cheeks, the pharynx, and in female children of the vagina, and these com- 
monly precede in point of time any manifestation of a similar affection of 
the pulmonary organs. 

Of the local causes which interfere with the circulation through the 
lungs the most common in children is probably the presence of a foreign 
body in the air-passages. The irritation of the intruding substance sets 
up a form of pneumonia which may run rapidly into gangrene. Of the few 
examples of the lesion which have come under my own care one was a case 
of this kind. It is narrated shortly in another chapter (see page 529). In 
cases where lobar pneumonia ends in mortification of the lung the gan- 
grenous lesion cannot be looked upon as a natural consequence of the pul- 
monary inflammation. Indeed, the inflammatory disease is often not a 
true croupous pneumonia, but an acute hepatisation of the lung resulting 
from the presence in the organ of some local irritant. Thus, a variety of 
pulmonary inflammation with which gangrene is often associated is that 
due to emboli swept into the pulmonary circulation from an ante-mortem 
clot formed in the right side of the heart. The irritation of these emboli 
causes complete stasis in neighbouring vessels, and sets up putrefaction 
and gangrene in the lung tissue around. Bouillard states that this ac- 
cident may happen in cases of true croupous pneumonia and determine the 



GANGEEXE OF THE LUNG— MORBID ANATOMY— SYMPTOMS. 497 

gangrenous change ; indeed, according to this observer, a peculiar ten- 
dency to the formation of such coagula is a common feature of the pneu- 
monic disease. But even if this be the case, the mortification of tissue is 
induced by something superadded to the original lesion, and is not to be 
regarded as an ordinary incident of the croupous form of pulmonary 
inflammation. 

The retention of decomposing secretions in dilated bronchi and cavities in 
the lung is another local cause of the gangrenous lesion in the child. It may 
arise in the course of phthisis, or at the end of an attack of acute catarrhal 
pneumonia. So, also, extensive hemorrhage into the lung, if it undergo 
putrefaction, is said to be a cause of gangrenous changes in the surround- 
ing tissue. No doubt in all these cases a debilitated or cachectic state of 
the system favours the occurrence of pulmonary gangrene ; but mortifica- 
tion of the lung may arise in children of sound constitution who are well 
nourished, and whose sanitary surroundings have been to all appearance 
satisfactory. 

Morbid Anatomy. — The commonest form in which gangrene of the lung 
is met with in the child is that of a patch of mortification situated in the 
centre of a lobe and surrounded by gray hepatised tissue. The gan- 
grenous patch consists of a pulpy detritus, yellowish-grey, dark green, or 
slate grey in colour, and intolerably offensive in its smell. It gradually 
breaks down and leaves a cavity with disintegrated gangrenous shreds ad- 
hering to its walls. This is the circumscribed variety in which the num- 
ber of sphacelated masses may be one or more. In some cases the diseased 
area is very small, and the lesion consists merely in greenish streaks of 
gangrenous odour and semi-liquid consistence in the centre of a broncho- 
pneumonic nodule. In other instances we find patches of catarrhal 
pneumonia enclosing small gangrenous abscesses of variable number, com- 
municating here and there with a bronchus. 

In the diffused variety the gangrenous change involves more or less of 
the whole lobe. Thus, in a case recorded by Dr. Hayes, after the death 
of the patient — a boy of seven years of age— the lower half of the inferior 
lobe of the right lung was in a state of grey hepatisation. Its tissue was 
very friable, and drops of pus exuded from it on pressure. The remainder 
of the lung was of a dark purplish colour. Its tissue broke down on the 
slightest pressure and gave forth an unbearable stench. The centre of 
the middle lobe was occupied by an irregular cavity, about the size of a 
large walnut, filled with putrid matter. 

In the circumscribed form the seat of the lesion is usually the lower 
lobe or the periphery of the organ. In the latter case the pleura may 
be inflamed or may participate in the sphacelating process. In my 
own case, related elsewhere, not only was the whole of the left lung in a 
state of gangrene, but adhesions had formed between the adjacent layers 
of the pleura at the posterior surface. Moreover, the chest-wall had been 
perforated in the eighth intercostal space, and a communication had formed 
between the disintegrated lung and an extensive abscess which lay outside 
the wall of the chest. 

If adhesion of the pleura does not occur, pneumothorax may arise from 
rupture of the lung into the pleural cavity. 

In many cases the bronchial glands are enlarged and cheesy. In two 
of Eilliet and Barthez' cases they were gangrenous. 

Symptoms. — The symptoms of the disease are often very indefinite. 
They may consist only of general drooping, disinclination to exertion, 
pallor and wasting, with slight cough and obscure pains about the chest. 
32 



498 DISEASE IN CHILDREN. 

The ' physical signs may be also indefinite, consisting merely of slight dul- 
ness at a certain part of the chest, with feebleness of breath-sound. After 
a time the child dies without any more characteristic symptoms having 
been developed, and the autopsy discovers a patch of gangrene in the lung. 
In almost all the cases observed by Rilliet and Barthez, these experienced 
physicians failed to detect the nature of the illness during the life of the 
patient. 

In more pronounced cases the disease may begin gradually or sud- 
denly. In the first case the child is noticed to be failing. His appetite 
is poor, he looks pale, and his flesh feels flabby. Soon he complains of 
pains in the chest, coughs occasionally, and sits by the tire if the weather 
is chilly, refusing to play, and objecting to any exertion. He is thirsty 
and sleeps restlessly at night, being often disturbed in his sleep by 
cough. 

The sudden onset may be announced by headache and sickness, a 
feeling of chilliness, or even a rigor. The child is feverish, with a dry skin ; 
is very restless and anxious, and the pulse is quickened. Perhaps there 
may be pain in the side and a dry cough. 

When the symptoms are fully developed the patient is pale and weakly 
looking, with a haggard expression of countenance, and dull, sunken eyes. 
The tongue is foul, and appetite is almost completely lost. The bowels 
are seldom relaxed ; sometimes there is marked constipation. There is 
often great restlessness, so that the child is in constant uneasy movement 
in his bed. The pulse is feeble and frequent, 130-150 ; the respirations 
30-40. The temperature is high, and may reach 103° or 104° in the even- 
ing, usually falling in the morning to 100° or 101°. The cough is frequent 
and loose. It is often excited by movement and may be accompanied by 
pains in the back or side. Usually there is expectoration even in young 
children, for the sputum is too offensive to be swallowed. It exhales a 
sickening odour, and is frothy and reddish-brown in colour. On standing 
it deposits a reddish-brown, shreddy sediment, containing greyish putrid 
granules, in which Leyden and Jaffe have discovered bacteria and a special 
fungus — the leptothrix pulmonaris. In quantity the expectoration varies 
from time to time, being sometimes copious, sometimes scanty and more 
tenacious. Occasionally the fetid odour ceases to be noticed, but it usually 
quickly returns. A similar odour is perceived in the breath of the patient, 
especially during cough. As in the case of the expectoration, its offensive- 
ness occasionally ceases for a time. The cough may be so harassing and 
frequent as almost entirely to prevent sleep ; and the consequent exhaus- 
tion, combined with the unwillingness of the child to take adequate 
nourishment, adds greatly to his weakness. 

In most published cases great variation has been noticed in the in- 
tensity of the symptoms. Sometimes the pulse is excessively frequent 
and feeble, the eyes sunken and lustreless, the restlessness extreme, the 
cough distressing, and the face earthy or lead-coloured. The breathing 
also may be laboured and difficult. Thus, in a case recorded by Dr. 
Sturges there were attacks of violent dyspnoea in which the face looked 
pinched and blue, the expression was terrified, the body was covered 
with a clammy sweat, and no pulse could be felt at the wrist. At other 
times the symptoms are less distressing, the face looks brighter, the cough 
is quieter, the pulse fuller, and the manner more composed. The patient, 
however, from day to day grows evidently weaker, and in the large majority 
of cases sinks after a further period of suffering. Sometimes death is 
preceded by one or more attacks of haemoptysis. In a case reported by 



GANGEENE OF THE LUNG — SYMPTOMS — DIAGNOSIS. 499 

Dr. Hayes, the child, on the afternoon before his death, after a fit of 
coughing, spat up half a pint of red, frothy blood ; and the haemoptysis 
was repeated in the evening shortly before he died. 

In some cases gangrene of the gums or cheek has been observed ; 
and if the signs from the lungs are not marked, the fetor of breath may 
be attributed to the presence of these lesions. 

The duration of the illness in cases which terminate in death is never 
very prolonged. Dr. L. Atkins, who has collected thirty-one cases of the 
affection, states that it varies between two days and twenty. The child 
usually dies from asthenia. The complexion grows more and more livid, 
the pulse weaker and more rapid, and death may be preceded by a gusli 
of blood from the mouth or by rupture of the lung and the formation of 
pneumo-thorax. 

In the rare cases in which recovery has been recorded, the fetor of the' 
breath disappeared at the end of a fortnight or three weeks ; but con- 
valescence was very slow. 

The physical signs in cases of pulmonary gangrene are not distinctive 
of the lesion. At first the signs are usually those of bronchitis. Percus- 
sion of the chest discovers no dulness, and with the stethoscope we find 
merely large bubbling rhonchus pervading the lung on both sides. After 
a few days a limited area of dulness is detected at some part of the chest- 
usually the posterior base ; the breath-sound becomes bronchial, and the 
rales are drier and more crepitating in character. The dulness usually 
extends its area and may pass to the front of the chest. If eventually a 
cavity form, it may give no evidence of its presence unless its situation be 
near the periphery. In that case the breathing may become bronchial, 
blowing, or cavernous, and the rhonchus larger and more distinctly gurg- 
ling. In the case of a large cavity amphoric respiration with metallic 
tinkle may be discovered at some point in the dull area. 

In a case which was under the care of my colleague Dr. Donkin, in the 
East London Children's Hospital — a microcephalic idiot, between two and 
three years old, who was admitted for rigidity and paralysis of joints, with' 
partial loss of consciousness — the breath a few days before death was noticed 
to have an insupportably offensive odour. The child began to cough slight- 
ly, and the pulse and respiration were greatly hurried. On examination of 
the chest dulness was discovered at the left base, passing round from the 
back to the front, being most intense beneath the left axilla. Much large 
bubbling rhonchus was heard all over both sides, especially the left. 
The child grew rapidly worse, the face became much pinched, and 
petechise appeared upon the abdomen. The temperature, which had 
been always high, rose to 108° shortly before death. An autopsy revealed 
two small embolic infarctions in the left lung. The lower lobe was com- 
pletely solidified, and contained a cavity the size of a lien's egg. This 
excavation was partially lined with a membrane, and held much stinking 
fluid and detritus. The right lung was merely congested with patches of 
collapse. 

In this case the high temperature noted before death was probably 
due more to the condition of the brain than to that of the lung. The 
cavity seems to have been the consequence of breaking down of an inflam- 
matory consolidation set up by a metastatic infarction, the gangrenous 
nature of the process being determined by the low nervous power of the 
patient. 

Diagnosis. — On account of the uncertain character of the symptoms 
and physical signs which present no definite features by which the disease 



500 DISEASE IN CHILDREN. 

can be recognised, we are forced to rely solely upon a gangrenous odour 
from the breath and expectoration for evidence of the nature of the 
lesion. Without this symptom there is really nothing in the condition 
of the child to suggest that the inflammatory process has gone on to 
mortification of tissue ; for a cachectic appearance, great feebleness, a hag- 
gard look, constant restlessness, and varying intensity of symptoms are 
common to many forms of illness. If the characteristic fetor of breath 
be present alone, it may be the consequence of other conditions. In 
gangrenous stomatitis and gangrene of the pharynx the same phenom- 
enon may be observed ; and in many cases of cirrhosis of the lung, 
when secretion is retained and becomes decomposed in the dilated tubes, 
the odour of the breath may be exceedingly offensive. In the latter dis- 
ease, although the breath and expectoration may be very offensive without 
obvious gangrene being present, shreds of sphacelated tissue are, no doubt, 
present in the matters discharged from the lung. If gangrene of the lung 
coincide with the same condition of the mouth the unpleasant odour is 
usually attributed to the lesion which is within reach of the eye, and the 
pulmonary gangrene may not improbably pass unrecognised. The ap- 
pearance of offensive expectoration, however, at once directs attention to 
the lung, and if haemoptysis occur, the blood giving out the same unbear- 
able odour, doubt is no longer possible. 

In infants and the youngest children expectoration is sometimes absent, 
but a gangrenous odour from the breath is seldom wanting. Fetor of the 
breath in such cases is the more characteristic, as fibroid induration of 
the lung is very rare below the age of six years, and gangrene of the mouth 
is not often met with during the first two years of life. 

Prognosis. — Recovery is so exceptional a termination of the disease that 
in any particular case the patient's chance of escape is very small. Varia- 
tions in the severity of the symptoms are a common feature of the illness, 
and we must not allow our hopes to rise too high merely because we find 
the child looking brighter and more composed, and notice that the fetid 
odour from the breath is no longer to be perceived. Such a favourable 
change is too often only a temporary improvement, to be followed, perhaps in 
a few hours, by a return of all the worst symptoms. If, however, the char- 
acteristic odour is not reproduced, and we find that the pulse becomes 
fuller and stronger, and the cough less distressing ; that the tongue begins 
to clean and the appetite to return, we may venture to hope that the favour- 
able change may be maintained. According to Kohts, when the gangrene 
results from the presence of a foreign body in the lung the prospect is 
less desperate than in other cases, but this can only be if the irritating 
substance is expelled. 

Treatment. — In the treatment of this distressing disease we must do 
our best to support the strength of the child and make energetic employ- 
ment of disinfecting and stimulating inhalations. 

The chamber should, if possible, be large, and must be kept thoroughly 
ventilated. It should be continually disinfected by spraying with carbolic 
acid or Condy's fluid, and pans of either disinfectant should stand about 
the room. 

The child should be made frequently to inhale vapours or sprays im- 
pregnated with oil of turpentine (TT[ xx.-xxx.) to the pint of boiling water, 
or with creasote or carbolic acid ( TT[ xx,-xxx. to the pint). Glycerine of 
carbolic acid may be also given internally, in one or two drop doses, accord- 
ing to the age of the child ; and Traube recommends the salicylate of soda 
or the acetate of lead. The sulpho-carbolates are said to be of service in 



GANGRENE OE THE LUNG — PEOGNOSIS — TREATMENT. 501 

removing fetor, if given freely. The sulpho-carbolate of soda may be given 
to a child of four years old in doses of four grains every six hours. Buc- 
quoy recommends the tincture of eucalyptus for the same purpose, and 
states that the remedy not only reduces the offensive odour of the breath 
and sputum, but relieves the violence of the cough. A child of four years 
old may take five or six drops three times a day. 

Quinine and the mineral acids are preferred by some ; and it is impor- 
tant that the former, if employed, should be given in full doses. For each 
dose the quantity may be calculated at one grain and a half for each year of 
the child's age ; and this may be given three or four times in the twenty- 
four hours. Ammonia and bark have also their advocates. The bowels 
must be kept regular. If they are confined a dose of castor-oil will usually 
relieve the constipation. 

Alcoholic stimulants are always required. For an infant white wine 
whey, for an older child the brandy-and-egg mixture should be given at 
frequent intervals. 

With regard to diet : an infant should be restricted to milk diluted with 
barley-water and guarded with a few drops of the saccharated solution of 
lime (twenty drops to the teacupful). An older child can take milk, strong 
beef-tea, pounded meat, eggs, etc., in quantities regulated according to his 
age and powers of digestion. In this, as in all other cases where the de- 
bility is great, we must remember that the digestion shares in the general 
weakness ; and must be careful not to overload the stomach or fill the 
blood with unassimilable nutriment in our anxiety to sustain the strength 
and obviate death from asthenia. 



CHAPTER XII. 

PULMONARY PHTHISIS. 

Pulmonary phthisis is a common disease in the child. The term signifies 
ulceration of the pulmonary tissue. The affection is therefore perfectly 
distinct from acute tuberculosis. The latter is a general disease in which 
the lungs, if they are involved at all, are affected in common with most 
other organs of the body, and if they undergo disintegration, break down 
as a consequence of inflammatory changes due only indirectly to the 
presence of the grey granulation. Pulmonary phthisis, even when the con- 
sequence of a general dyscrasia, is especially a lung disease, which if it run 
its course unchecked passes on necessarily to softening and excavation. 

Phthisis may be acute or chronic. The acute form is not uncommon in 
young subjects, and consists in rapid hepatisation and caseous infiltration 
of the lungs, with equally rapid softening and disintegration. This form 
of the disease is to be distinguished from acute pulmonary tuberculosis, 
although it may be combined with it. 

Chronic phthisis is seen in two principal forms, viz., chronic tubercular 
phthisis and catarrhal or pneumonic phthisis. These varieties differ mark- 
edly in their mode of origin, their course, and often in their termination, 
and are, no doubt, the consequence of very distinct pathological conditions. 

Causation. — Most cases of pulmonary phthisis are dependent upon a 
general predisposition, which may be hereditary or acquired. The child 
may be born into a consumptive family and thus inherit a constitutional 
delicacy which renders him especially sensitive to morbific influences. On 
the other hand, although without any family tendency to this form of ill- 
ness, the patient may yet, through the agency of special disease, aided per- 
haps by insanitary surroundings, acquire a pulmonary weakness which 
sooner or later, under suitable conditions, developes phthisical changes in 
the lung. 

The inherited disease may consist of either form of phthisis ; and 
either variety may be acquired by a child in whose family no tendency to 
consumption can be discovered. Even chronic tubercular phthisis, al- 
though in the majority of cases no doubt the consequence of an inherited 
predisposition, may be excited by infective agency through the presence of 
softening cheesy matter at some part of the body. A special pulmonary 
delicacy is often the consequence of whooping-cough and measles. These 
diseases are very liable to be complicated by catarrhal pneumonia, and it 
often happens that after convalescence the absorption of the consolidating 
material is incomplete. Consequently a caseous lump is left at some part 
of the lung, which after remaining inactive for a shorter or longer period 
begins at length to soften and set up irritation in its neighbourhood. But 
even if perfect absorption of the consolidating material take place, a certain 
susceptibility may be left after the subsidence of the inflammation, so that 
the child becomes attacked again and again by obstinate catarrhs. These 



PULMONAKY PHTHISIS — CAUSATION. 503 

catarrhs in favourable subjects are apt to lead to cellular infiltration of tlie 
bronchial walls and gradual invasion of the alveoli. In this way a catarrhal 
or pneumonic phthisis is eventually developed. 

In children of scrofulous tendencies there is very commonly a pulmo- 
nary weakness. The child is very subject to catarrhs, and he has also the 
proneness inseparable from his strumous constitution to rapid prolifera- 
tion and caseation of cellular elements. In such a subject a catarrhal 
phthisis is readily set up. So, also, in subjects especially prone to tuber- 
cular formation the lung irritation may induce this variety of pathological 
change. In the present day, owing to the discovery by Koch of the tuber- 
cle bacillus, there is a tendency to look upon all forms of phthi&is as due to 
infective agency. According to this view, the various pathological condi- 
tions would be all tubercular, as the bacillus appears in most cases to be 
discoverable either in the sputum or the pulmonary tissue of the part 
affected. The question, however, is as yet far from settled ; and looking at 
the wide differences in the clinical characters of the several forms of pul- 
monary phthisis, it seems desirable to consider these diseases from a clinical 
rather than from an anatomical point of view. 

The causes which tend to originate a pulmonary weakness or encourage 
a natural delicacy of lung are all those which in any way help to lower 
nutrition and depress the natural vigour of the body. In childhood — a 
period of life in which nutrition is only maintained at a healthy standard 
by the continual influx of nutritive material — any interference with the 
digestive or assimilative processes has an exceptional influence in diminish- 
ing resisting power. It is for this reason, probably, that in unwholesome 
conditions of living slight febrile attacks, such as are incidental to many 
of the less serious ailments of early life, may start an enfeebling process 
which ultimately determines phthisical changes. In this way unsuitable 
food and close rooms, "a damp residence, mental depression from unkind 
treatment, over-exercise of the immature brain, and any other like agency 
may have an influence in exciting the mischief in the lung. 

Certain diseases have an undoubted tendency to be followed by 
phthisis. On this account measles and whooping-cough are justly dreaded 
for the injurious influence they are known to exercise upon scrofulous and 
weakly subjects. These affections not only encourage a special lung 
weakness, but also by promoting enlargement and caseation of the lym- 
phatic glands, may set up a focus of infection by which, through the 
medium of the blood-vessels or lymphatics, secondary inflammatory pro- 
cesses of a more or less acute character may be excited in the lung, 
Scarlatina, too, is sometimes a cause of phthisis, acting by similar means ; 
empyema may induce the pulmonary mischief through absorption of 
infective material from the pleura ; and the disease not uncommonly 
arises in children who suffer from scrofulous joints and old-standing 
caries of bone. The influence of catarrhal pneumonia in inducing the 
disease has been already referred to. 

Since the discovery of the bacillus the question of the infectiveness of 
phthisis from person to person has again assumed considerable prominence. 
The presence of bacilli has been discovered in the air expired by con- 
sumptive patients ; and if this microphyte be indeed the agent by which 
the infection is conveyed, it would seem to follow as a logical conclusion 
that the disease must be continually communicated by this means. 
Whether, however, it be that a predisposition of rare intensity is required 
for the ready reception and development of the bacillus, or that the im- 
portance of this organism as an infecting agent has been overestimated, 



504 DISEASE IN CHILDEEN. 

the fact remains that the disease is practically not communicable by this 
means. 

Morbid Anatomy. — In all cases of pulmonary phthisis the lungs after 
death are found to be more or less consolidated by a cheesy-looking sub- 
stance which is in various stages of softening and disorganization. 
Whether the disease has begun by a chronic process of tuberculisation, 
or has originated in a catarrhal pneumonia and epithelial accumulation in 
the alveoli, the degeneration of the morbid material gives rise to caseous 
solidification of very similar character. Even when the primary patho- 
logical change consists in a chronic formation of grey tubercle in the 
lung tissue, a secondary catarrhal pneumonia is usually set up sooner or 
later ; and the resulting caseous infiltration materially contributes to the 
enlargement of the area of solidification. Again, when the form of 
phthisis is originally catarrhal, softening of the cheesy material which 
infiltrates the lung may be a source of infection. By this means a second- 
ary formation of miliary tubercle is excited, at first in the immediate 
neighbourhood of the affected region, afterwards more generally over both 
the lungs. Consequently, in most cases, the pathological changes are not 
simple, but tend to complicate one another, so that the lung is at the same 
time the seat of different morbid processes. We often find grey or yellow 
granulations combined with masses of yellow infiltration of various extent. 
In these masses the tissue is soft and friable, and on section is found to 
be dryish, of a straw or grey colour, and streaked or spotted with black 
pigment. The surface is commonly marked with intersecting lines which 
indicate the position of the interlobular septa. At the borders of the con- 
solidated region is usually a zone of reddish-grey glutinous infiltration. 
Often many of these caseous masses are seen scattered over the lung, 
the pulmonary tissue between them being cedematous or congested, and 
partially collapsed. 

If the phthisis has reached an advanced stage, cavities from breaking- 
down of the consolidating material are usually found. Cavities are not 
uncommon in the young subject, and are probably met with less frequently 
in the child than in the adult, only because the disease in early life often 
proves fatal from a secondary tuberculosis or other exhausting complica- 
tion before the stage of excavation has been arrived at. When softening 
begins, it always occurs first in the centre of the caseous mass. The clead 
shrunken cells and molecular debris lying around them are loosened by 
the imbibition of watery fluid, and the cheesy material is converted into 
a soft purulent pulp. The wall of the bronchus, which lies in the centre 
of the nodule, then becomes perforated, and the cheesy matter is coughed 
up, leaving a ragged excavation. The softening may attack the cheesy 
masses generally through the lung, as happens in the more acute form of 
the disease ; or may begin in those situated in the upper part of the lung, 
and thus pass gradually from apex to base. The expectorated matter in 
these cases contains particles of elastic tissue and shrunken cells, and 
often under the microscope exhibits bacilli in large quantities. 

In cases where the disease consists principally of the grey and yellow 
miliary nodules, these bodies are seen grouped in clusters and more or 
less closely aggregated. They are more numerous towards the apex ; but 
sometimes the whole of both lungs may be seen to be stuffed with them ; 
and in some parts, in addition, there may be softening cheesy masses, 
more or less disintegrated. In most cases the lungs are also found to be 
the seat of increased fibrosis, and some dilatation of the smaller air-tubes 
can be perceived. 



PULMONARY PHTHISIS — MORBID ANATOMY — ACUTE. 505 

The real tubercular phthisis attacks both lungs simultaneously. The 
catarrhal form begins in one lung, and it is not until signs of softening are 
noticed that the opposite lung becomes affected. This softening of the 
cheesy matter in the affected lung is often a signal for a more general 
diffusion of the disease. The apex of the opposite lung is attacked, and 
caseation and softening occur in the glands of Peyers patches and in the 
solitary follicles in the neighbourhood of the ilio-csecal valve, giving rise 
eventually to ulceration of the bowels. 

On microscopical examination of the lungs, the seat of pulmonary 
phthisis, various histological changes are discovered. According to Dr. T. 
Henry Green, these are mainly of four kinds : 1st, a filling of the pul- 
monary vesicles with fibrinous exudation and leucocytes ; 2d, an accumula- 
tion of large epithelial cells within the alveoli ; 3d, an infiltration and 
thickening of the walls of the air-vesicles, and often also of the terminal 
bronchi with small cells ; 4th, an increase of the interlobular connective 
tissue. These various changes occur in varying degrees in different cases, 
but all of them are said to be present in the majority of instances, although 
in very different proportions. 

In a practical treatise it is unnecessary to enter minutely into the 
various pathological changes which combine to make up a case of pul- 
monary phthisis ; and the reader is referred to the standard works on 
pathological anatomy for fuller information upon this subject. The pre- 
ceding sketch is necessarily brief and imperfect ; but some reference to 
the conditions which give rise to the signs and symptoms about to be 
enumerated was indispensable. 

The acute and chronic forms of pulmonary phthisis will be described 
separately. 

ACUTE PHTHISIS. 

Acute phthisis, or " galloping consumption," is not uncommon in early 
life. The term is sometimes used to include cases of acute pulmonary 
tuberculosis. It is, however, more properly restricted to cases of rapid 
catarrhal pneumonia where, as a result of an acute inflammatory process, 
the air-cells become stuffed with epithelial elements which undergo rapid 
caseation, and the solidified tissue quickly breaks down into cavities. The 
consolidation is at first lobular and is generally diffused over the lungs. 
Softening takes place pretty equally in all parts at the same time, so that 
the lung becomes destroyed by sinuous and burrowing cavities separated 
by reddened and ©edematous tissue ; much purulent matter is formed, and 
the lining membrane of the air-passages is excessively red. In this form 
miliary tubercle may occur as a complication, but its appearance is com- 
paratively rare, for the disease is essentially pneumonic in its nature. 

Acute phthisis generally occurs in a child who has been reduced in 
health by previous illness or bad hygienic conditions, and is sometimes 
seen to attack one already the subject of a chronic consolidation which had 
given rise to but few symptoms. The age of patients so affected is usually 
five or six years and upwards. 

Symptoms. — The general features of the illness are those of an acute 
attack of pneumonia combined with very great severity of the general 
symptoms. At first the child usually complains of a pain in the side. 
This may come on quite suddenly during some slight muscular exercise. 
Thus, in a little girl under my care, the child first complained while she was 
helping her mother to make a bed. The pain niay subside after a time, 
or be complained of occasionally all through the illness. Cough comes on at 



506 DISEASE IN CHILDKEN. 

the same time with the pain, and the child is noticed to be very feverish at 
night. In older children the cough is usually accompanied by expectora- 
tion. The sputum is at first whitish and aerated, but as the lungs begin 
to break down it becomes yellow or greenish and nummulated, and is 
found to contain large quantities of yellow elastic tissue. The number of 
bacilli found in the sputum is not, however, always very great. In some 
cases under my care these organisms were found in much less quantities 
than in cases of phthisis which ran a more chronic course. 

Dyspnoea is always an early symptom ; the appetite is very poor, thirst 
is great, the tongue is furred, the bowels are relaxed or confined, and the 
child wastes with extreme rapidity. In some cases swelling of the abdomen 
is noticed, and the liver may be found to be enlarged from fatty infiltration. 

The fever is often very high. It is not uncommon to find that the tem- 
perature rises to 104° or 105° at night, sinking to 100° or 101° in the 
morning. It soon begins to be accompanied by copious sweats, and the 
night-clothes may be drenched by the profuseness of the secretion. 

Examination of the chest discovers principally the signs of broncho- 
pneumonia. Dulness is noticed, usually beginning at the upper part of the 
lung. At the onset this may be limited to one side of the chest, but the 
opposite lung becomes very quickly affected. That first attacked, how- 
ever, generally maintains its precedence and keeps in advance of its fellow 
throughout the course of the disease. The diminution of resonance in- 
volves more and more of the area of the lung, and is accompanied by 
bronchial or blowing breathing which may be more or less covered by a 
copious, coarse, subcrepitant rhonchus. This rale is usually heard over 
the whole extent of both inspiration and expiration, and is very large and 
metallic in quality. In spots here and there cavernous respiration may be 
heard after a time ; and the rhonchus in such places is larger and more 
ringing than elsewhere. If a cavity of some size form, the breath-sounds 
may be amphoric. Vocal resonance is usually stronger than natural, and 
may be bronchophonic in places. 

The above are the physical signs in a typical case of the disease ; but it 
must be confessed that in many cases, especially in the younger children, 
cavities may form in the lung without any sign of their existence being 
noticed on examination of the chest. In such cases the signs are chiefly 
those of catarrhal pneumonia ; but the dulness begins at the upper part of 
the chest instead of the lower, and the rhonchus is usually larger and more 
ringing and metallic than in an ordinary case of broncho-pneumonia. The 
child in all cases looks excessively haggard and ill. The wasting is very 
rapid ; in a surprisingly short time the temples and cheeks get hollow, and 
the flesh seems to fall away from the body. Often more or less general 
cedema is noticed, although an examination of the urine may discover no 
trace of albumen. 

A little girl, aged thirteen years, was said to have been healthy until the 
age of six years, when she had an attack of measles followed very shortly 
by scarlatina. Enlarged glands formed in her neck soon afterwards, and 
some of these suppurated. Since that time the girl had been delicate, but 
had never coughed until ten months before coming under observation. 
For four months her cough had been very distressing, and she had suffered 
much from pain in the side. She had been very feverish, had sweated 
profusely at night, and had wasted rapidly. 

The girl was much emaciated and very weak. She had a distressed, 
haggard expression. The cervical glands were enlarged, and her neck bore 
many scars resulting from former suppurations. On examination of the 



ACUTE PULMONARY PHTHISIS — DIAGNOSIS — PROGNOSIS. 507 

chest the clavicles were seen to be very prominent from retraction of the 
apices of the lungs. There was much diminution of resonance over the 
whole of the right side and at the upper third on the left ; and much coarse, 
metallic, bubbling rhonchus was heard over the whole of both sides. The 
respiration was cavernous towards each apex, and bronchial below. The 
liver was enlarged, reaching nearly to the navel. 

The girl complained greatly of dyspnoea and sweated freely at night. 
Her cough was troublesome, and she expectorated nummular sputa. She 
said the sputa had never contained blood. Her face and feet were oedem- 
atous, and her urine contained albumen. There was no diarrhoea. 

During the first few days the girl's temperature was 101° at night, sink- 
ing to the normal level in the morning. It then became subnormal both 
morning and evening, and the patient died on the twelfth day after admis- 
sion into the hospital. On inspection of the body cavities were found at 
the upper part of each lung, and other small collections of purulent matter 
were scattered over both organs. The pulmonary tissue generally was red, 
and easily broke down under the finger. At the base of the right lung a 
marked increase in the fibrous tissue was noticed, and the bronchial tubes 
in that situation were somewhat dilated. No grey or yellow tubercles 
were to be seen. The pleural surfaces were firmly adherent. The kidneys 
appeared to be healthy. 

Death is preceded in these cases by great prostration, restlessness, and 
inability to sleep, complete anorexia, a glossy eroded tongue, and sordes 
upon the teeth and lips. The duration of the illness is comparatively 
short, and death usually takes place at the end of five or six months. 

Diagnosis. — The disease with which acute phthisis is most liable to be 
confounded is acute pulmonary tuberculosis. In the beginning, however, 
the affection may be mistaken for croupous pneumonia. The sudden 
onset, accompanied by pain in the side, cough, and high fever, presents 
sometimes a close resemblance to an ordinary case of inflammation of the 
lung. Still, the temperature does not maintain the same little varying 
elevation in acute phthisis as in croupous pneumonia, and the course of 
the illness in the two cases is very different. Instead of the sudden crisis 
which occurs in pneumonia about the end of the first week, the symptoms 
persist and grow more and more severe, the signs of consolidation con- 
tinue to extend themselves, the opposite lung is quickly affected, and 
very soon elastic tissue, and perhaps bacilli, can be discovered in the 
sputum. 

From acute pulmonary tuberculosis the disease is distinguished by its 
more abrupt onset, the early signs of pulmonary consolidation, and the 
absence of indications pointing to the implication of other cavities of the 
body. Comparatively few cases of pulmonary tuberculosis in the child 
terminate without some signs of intracranial mischief ; but when acute 
phthisis is uncomplicated by tuberculosis these are absent. The two 
diseases are, however, sometimes present together. The existence of the 
tubercular malady is then made evident sooner or later by the onset of 
convulsions, squinting, rigidity of joints, and other symptoms pointing to 
meningitis. 

Prognosis. — Acute phthisis is a very fatal disease, and the prognosis is 
consequently very unfavourable. The patients do not invariably die, but 
instances of recovery are exceptionally rare. In any case the best we can 
hope for is a remission in the acuteness of the symptoms. Sometimes the 
disease, its first force expended, loses a part of its energy and becomes 
more measured and tranquil in its course. It may even settle down into 



508 DISEASE IN CHILDREN. 

an ordinary case of chronic phthisis. It is impossible in any individual 
instance to anticipate such a result ; but a diminution in the pyrexia, if 
combined with an improvement in the appetite and a brighter expression 
in the face of the child, is a sign of good omen. A decrease in the fever, 
if unaccompanied by other signs of improvement, so far from being a 
favourable symptom, is one to be regarded with great anxiety ; and if, 
under such circumstances, the temperature fall to a subnormal level, it 
may be an indication that the end is not far off. 

The treatment of these cases will be considered afterwards. 



CHRONIC PULMONARY PHTHISIS. 

The two principal forms in which chronic pulmonary phthisis usually 
presents itself in the child have well-marked and very distinctive char- 
acters. Chronic catarrhal or pneumonic phthisis, which begins as a slowly 
forming consolidation of one lung, or succeeds to an attack of acute catar- 
rhal pneumonia from imperfect absorption of the solidifying material, has 
at first the characters of a local disease. It is accompanied by certain signs 
and symptoms which indicate the existence of irritation within the lung ; 
but as a rule the general health is comparatively little interfered with, 
nutrition is fairly performed, and the appearance of the child gives little 
evidence of serious pulmonary mischief. It is only when softening is set 
up at the seat of consolidation, and infection of the system follows with 
secondary deposits in the opposite lung and other parts of the body, that 
signs occur indicating that the patient is suffering from a general disease. 
Even when these general symptoms arise, they remain for a long time 
insignificant as compared with the signs of extensive disease discovered on 
examination of the chest. On the other hand, chronic tubercular phthisis 
has completely different characters. From the first — indeed, before any 
signs of pulmonary irritation have been noticed — there is some fever and 
wasting, showing general distress of the system ; and throughout the 
whole course of the illness the general symptoms continue severe out of 
all proportion to the actual extent of lung mischief discoverable by the 
stethoscope. Therefore, whatever opinions may be held with regard to 
the pathology of these two varieties, they still remain two distinct clinical 
types marked out from one another by very separate and distinctive 
features. 

Symptoms. — The peculiarities in the size and shape of the chest often 
met with in children of consumptive tendencies are elsewhere referred to 
(see page 399). It may, however, be remarked that although small lungs 
and a narrow elongated chest are often found associated with an inherited 
pulmonary weakness, phthisis is not confined to such subjects. We shall 
never be justified in excluding pulmonary phthisis because the child's 
shoulders are broad and his chest well proportioned. In the pneumonic 
form of phthisis the eye often detects nothing to raise a suspicion of pul- 
monary mischief. It is the tubercular variety which is most constantly 
combined with narrow sloping shoulders and flattened ribs. 

In both varieties of phthisis we find local symptoms significant of pul- 
monary distress, and general symptoms arising from irritation of the 
system and impaired nutrition. The severity of the case is usually very 
fairly indicated by the degree in which the latter predominate over the 
former. 

In chronic pneumonic phthisis the first sign of the disease is usually 



CHRONIC PULMONARY PHTHISIS — SYMPTOMS. 509 

cough. The patient may have lately passed through an attack of acute 
catarrhal pneumonia, or may have suffered from neglected pulmonary 
catarrh with gradual implication of the alveoli at one apex. In the first 
case the child recovers his strength but slowly. He continues to cough, 
often violently ; and is more or less feverish at night. After a time, how- 
ever, the fever subsides, and the child regains flesh and a certain propor- 
tion of his strength ; but he still looks pale and has a frequent hacking 
cough. In the second case the disease creeps on insensibly, and at last it is 
noticed that the child coughs, and is pale and easily tired. However the 
disease may have originated, the symptoms are insignificant as long as the 
unabsorbed deposit in the lung is undergoing no active change. A child 
with an unabsorbed mass of caseous matter in his lung may be plump, 
active, and cheerful ; but he is usually rather pale, may complain of pains 
in the limbs, and is apt to cough a little in the morning or in the day 
after exertion. On examination of the chest at this period we find slight 
dulness with some little increase of resistance at the apex or any other 
part of the chest on one side. If at the apex, the dulness is best detected 
at the supra-spinous fossa. The breathing is bronchial and some coarse 
clicks are heard with inspiration. The resonance of the voice is also in- 
creased. Children with the lung in this condition are very susceptible to 
chills ; and if first seen when the lungs are the seat of a fresh catarrh, 
general bubbling may be heard all over the diseased side ; and also, but 
to a less extent, over the opposite lung. When this happens it is difficult 
to form a correct opinion as to the actual amount of disease present in the 
chest ; and it is well to correct our first impressions by the results of a 
subsequent examination. 

At this stage of the illness, before softening has begun, absorption is 
still possible, and sometimes occurs in young subjects many months after 
the first symptoms have been noticed. 

When softening begins the general symptoms become more pro- 
nounced. There is fever, the evening temperature risiug to 102° or 103°; 
there is marked pallor, although the cheeks become flushed towards 
night ; and the expression is distressed. Often the child sweats towards 
the morning. These symptoms indicate an infection of the system by 
absorption from the softening area. The disease from being local is 
becoming general ; and the consequences are quickly seen in the inter- 
ference with nutrition which never fails to ensue. The child begins to 
lose flesh and strength ; his spirits fail ; his appetite and digestion become 
poor, and he shows all the symptoms of suffering. The course of the 
disease is almost always unequal. Every now and again an improvement 
is seen to take place. By careful nursing and treatment the fever dimin- 
ishes or subsides ; the nutrition improves ; and flesh and strength are 
regained. It is not uncommon to see a child fairly plump and to all 
appearance in tolerable health, who yet has a cavity in one lung and signs 
of consolidation at the opposite apex. 

During this stage pains are often complained of in the shoulder of the 
affected side. They come and go, and seldom continue for long together. 
The respirations are usually more hurried than in health, but when the 
child is quiet are not necessarily much exaggerated. The increased fre- 
quency of breathing is a cause of no inconvenience to the patient, and 
unless after exertion does not give rise to a feeling of dyspnoea. The 
cough is frequent and fairly loose. If expectoration occur, the sputum 
consists of yellowish or greenish muco-purulent matter which under the 
microscope is found to contain fragments of yellow elastic tissue and 



510 DISEASE IN CHILDREN. 

often bacilli, the latter perhaps in large quantities. Haemoptysis is rare, 
but does occur in exceptional cases. Children accustomed to a sufficiency 
of good food seldom have much appetite, and often show a complete dis- 
gust for food. In hospital patients, however, the appetite may remain 
keen ; and a child with cavities in his lungs and a high temperature may 
be seen to enjoy his meals almost as if he were well. The digestion is 
usually impaired, and, probably from the quantity of acrid mucus which is 
swallowed, vomiting is not uncommon. Diarrhoea, too, is a familiar symp- 
tom. In cases where the appetite is preserved nutrition may seem for a 
time to go on fairly well in spite of the pyrexia. Hospital patients often 
gain weight after admission, although the evening temperature may stand 
every night at 102° or 103°. 

The physical signs in the stage of softening consist of an increase in 
the dulness, for the irritation set up by the changes occurring at the diseased 
spot induces an extension of the catarrhal process ; and an alteration in 
the quality of the breathing, which becomes blowing or even cavernous. 
It is accompanied by a moist crackling rhonchus which, as a cavity forms, 
becomes very metallic and ringing. At this time the apex of the opposite 
lung should alwa} T s be carefully examined. In many cases slight loss of re- 
sonance with high-pitched or faintly bronchial breathing will be found at 
the supra-spinous fossa, and a click or dry crackle can be heard at the end 
of inspiration. It is at this period of the illness that diarrhoea is especially 
frequent ; and if caseation and softening occur in the solitary follicles of 
the intestine and the glands of Peyer's patches, the stools may soon begin 
to present the characters peculiar to ulceration of the mucous membrane 
(see page 662). If this complication occur, the child wastes rapidly and be- 
comes haggard and hollo w-eyed. He sweats profusely at night ; is rest- 
less ; refuses food ; and quickly dies with all the symptoms of prostration. 
The temperature in these cases seldom reaches a high elevation. It is 
usually between 101° and 102° in the evening. 

Children who are the subjects of a chronic caseous consolidation of the 
lung often suffer from attacks of secondary catarrhal pneumonia. In these 
attacks the boundaries of the original mischief are not always extended. 
It is common to find the chief force of the complication expended upon a 
different part of the lung. Thus, a child with signs of consolidation at the 
apex of the right lung is attacked with catarrhal pneumonia. A loud crep- 
itating rhonchus is heard all over both sides of the chest, and at the right 
posterior base there is some dulness with tubular breathing and a metallic 
quality of the rhonchus. The basic dulness becomes gradually more pro- 
nounced, and at this spot the respiration gets to be cavernous or even am- 
phoric, and the rhonchus to be excessively metallic and ringing. The vocal 
resonance is bronchophonic. The temperature rises to 103° or 104° in the 
evening. After two or three weeks the temperature begins to fall and the 
dulness to diminish ; the hard metallic rhonchus becomes looser and more 
bubbling ; the cavernous breathing is less intense at the base, and the gur- 
gling is less large and metallic. The child begins to regain flesh, and when 
lost sight of, although looking plump and well, has still the old mischief at 
the apex, and the signs of consolidation with cavernous breathing still per- 
sist at the base of the lung. In such a case, which is no imaginary one, the 
child recovers from his intercurrent attack with two consolidations instead 
of one. The catarrhal pneumonia has given rise to a cheesy deposit at the 
base of the lung and dilatation of the bronchi. This, of course, if the 
patient be placed under favourable conditions, may possibly be recovered 
from ; but the probable consequence of such a condition, if time be allowed 



CHRONIC TUBERCULAR PHTHISIS— SYMPTOMS. 511 

for the change, is the development of a fibroid overgrowth at the spot and 
permanent bronchiectasis. 

An attack of broncho-pneumonia is often a cause of death, or the patient 
dies worn out with fever, diarrhoea, cough, and want of sleep. In not a 
few cases a secondary tuberculosis supervenes, or the case may be compli- 
cated by a more chronic and less general formation of miliary tubercle 
confined to the lungs. These are called cases of tuber culo -pneumonic 
phthisis. 

CHRONIC TUBERCULAR PHTHISIS. 

In this form of the disease the illness begins in a very gradual manner, 
and the special symptoms arising from the lungs are preceded by others 
showing the existence of general disorder of health. The child is noticed 
to be languid and listless. He looks pallid ; has little appetite ; complains 
of pains in his legs, and is disinclined for his usual games. He is often 
found to flush at night and his hands are noticed to be hot. After these 
symptoms have continued for several weeks the patient begins to have a 
slight cough. This at first is merely a short occasional hack which excites 
little attention ; but after a time it becomes more frequent and annoying. 
The course of the illness in this variety is less irregular than in that previ- 
ously described ; but still the downward progress is more rapid at some 
times than at others. The temperature, although it undergoes consider- 
able variations, rarely stands at a normal level in the evening ; but unless 
the disease be complicated with catarrhal pneumonia the pyrexia is not 
high and seldom reaches 102°. Wasting is usually persistent ; but if the 
patient has been exposed to privation, the comforts of a hospital may in- 
duce a temporary improvement in nutrition, although the pyrexia con- 
tinues and the other symptoms remain unaltered. Cough for a long 
time may be a very insignificant symptom and, even with signs of extensive 
disease of the lungs, may be almost absent. The breathing is often rapid, 
rising to thirty or forty in the minute. Increased hurry of breathing, 
according to Niemeyer, may be one of the earliest local symptoms, occur- 
ring before any physical signs of the disease can be discovered in the 
chest. The digestive organs are weak and irritable. Yomiting is common 
and is often excited by cough. Purging is also a frequent symptom. In 
many cases Examination of the belly discovers fatty enlargement of the 
liver, and oedema is often noticed in the limbs. Death may occur from 
general weakness, from catarrhal pneumonia, or from the extension of the 
tubercular formation to other parts. 

The physical signs of tubercular phthisis appear late, and at first are 
curiously insignificant when compared with the severity of the general 
symptoms. We find a child pale and thin, with a depressed, saddened look. 
The borders of his mouth have a faint blue tint ; he pants after exertion, 
and coughs occasionally a short hard hack. We are told that he has been 
failing for several months ; that he eats scarcely anything ; has lost all his 
spirits, and gets flushed and feverish at night. On examination of his 
chest we discover merely some slight want of resonance at the apices of 
the lungs with weak, harsh breathing. A faint dry crackle of rhonchus is 
caught at the end of inspiration, and is brought out more clearly by a 
cough. The chest is elongated, with a narrow antero-posterior diameter, 
but the lungs, although naturally small, appear healthy except for the 
signs which have been mentioned. 

As the disease progresses the physical phenomena become more pro- 



512 DISEASE IN CHILDREN. 

nounced. They are always discoverable at both apices, although more 
marked on one side than on the other. Usually the area of dulness is in- 
creased by a pneumonic process set up in the lung ; and marked dulness 
with blowing breathing and the ordinary signs of consolidation are dis- 
covered. The disease then after a time presents much the same characters 
to physical examination as those referred to in describing the catarrhal 
variety of phthisis. In exceptional cases disorganisation goes on without 
the aid of a pneumonic process. We then find the feeble breath-sound to 
become gradually blowing, and eventually cavernous sounds are discovered 
at the apex. 

Tubercular and tuberculo-pneumonic forms of phthisis are often met 
with in scrofulous children who suffer from long-standing disease of the 
joints. In such cases the articular affection has probably been the original 
cause of the pulmonary mischief ; and by the continual irritation to which 
it gives rise may influence the condition of the patient very unfavourably. 
In these cases it is often advisable to remove the diseased joint, even al- 
though the amount of disease in the lung is too extensive to allow of last- 
ing improvement. Life may be considerably prolonged and the comfort 
of the patient greatly promoted by this step. 

A little girl, aged eight years, was a patient in the East London Chil- 
dren's Hospital under the care of my colleague, Mr. K. W. Parker. The 
girl's father had died of consumption, and she herself had been suffering 
from strumous disease of the right astragalus for six months. The child 
was much emaciated and very anaemic and feeble. Her skin was harsh and 
dry, her eyelids were swollen ; and the cervical and inguinal glands of 
each side could be felt to be- enlarged. The finger ends were somewhat 
thickened. There was no albumen in the urine. The temperature was 
usually normal in the morning, but would rise towards night to between 
101° and 103°. At Mr. Parker's request I examined the child's chest, and 
found the signs of a cavity at the upper part of the right lung, with evi- 
dence of considerable consolidation over the lower lobes. The left lung 
was also diseased, although to a less extent. A moist crackling rhonchus 
was heard over both sides of the chest. Although this child was evidently 
suffering from tuberculo-pneumonic phthisis, and the pulmonary mischief 
was very extensive, the system was obviously so greatly distressed by the 
irritation and pain of the diseased ankle, that Mr. Parker decided upon 
amputating the foot. After the operation the temperature, which on the 
previous evening had been 101.6°, fell to 98° at 6.30 p. m., and remained 
for the most part at a normal level while the child remained in the hospi- 
tal. The clicking rhonchus also ceased to be heard in the chest ; the face 
lost its distressed look ; and nutrition improved in a surprising manner, 
the patient gaining between six and seven pounds in three weeks. Unfor- 
tunately, after the child left the hospital and returned to her own poor 
home, the improvement was not maintained, and in a few months we heard 
that she was dead. Still the remarkably good results which followed the 
removal of the diseased joint are very instructive, and fully justified the 
operation. 

The majority of cases of pulmonary phthisis are seen in children of six 
or seven years and upwards ; but younger children and even infants are 
subject to the disease. In very young patients ulceration of the lung is 
not always easy to recognise. Serious disease may be present without giv- 
ing rise to any very characteristic symptoms. The child is no doubt feeble 
and wasted, but loss of flesh and strength are common in very young chil- 
dren with almost any form of illness. Cough may be trifling and the breath- 



CHKONIC PULMONAEY PHTHISIS — DIAGNOSIS. 513 

ing not obviously interfered with. Even a physical examination of the 
chest may yield us little information, for over the site of a cavity the per- 
cussion note may be merely tubular (tympanitic) and the breathing bron- 
chial with, moist clicking sounds. Moreover, the occurrence of softening 
in a cheesy pulmonary deposit is usually a signal for the occurrence of 
secondary deposits elsewhere ; and cheesy and ulcerating intestinal glands 
with the consequent diarrhoea may completely draw away the attention from 
the lungs. When pulmonary phthisis occurs in the young child, it runs a 
comparatively rapid course. It is in the large majority of cases primarily 
of the catarrhal form, and is most commonly the consequence of an attack 
of sub-acute broncho-pneumonia succeeding to measles or whooping-cough. 

Diagnosis. — In the diagnosis of pulmonary phthisis in the child an accu- 
rate account of the beginning and course of the illness is very important. 
At the same time it is necessary to remember that a history of cough with 
persistent loss of flesh is no sufficient proof that the child is suffering from 
pulmonary consumption. Scrofulous children and others with a like sus- 
ceptibility to chills, are very subject to attacks of pulmonary and intestinal 
catarrh. Such patients may be troubled with continual cough, and lose 
flesh steadily without any organic mischief being set up in the lung. They 
may even be feverish at the onset of every new chill without this additional 
symptom being evidence of phthisis. No doubt the condition of such chil- 
dren is one of danger, for they often eventually develop pulmonary dis- 
ease ; but until this has actually taken place, ordinary precautions for the 
avoidance of chills will quickly cause the symptoms to disappear. 

Even if examination of the chest discovers slight dulness at the supra- 
spinous fossa of one side with a high-pitched or faintly bronchial quality 
of breathing, these signs are not necessarily due to phthisical consolida- 
tion. Weakly children are very liable to temporary collapse at the apices 
of the lungs from insufficient expansion. In such cases the morbid signs 
are limited strictly to one aspect of the chest — the back or the front — and 
can often be made to disappear if the child is instructed to take two or 
three full inspirations in rapid succession. 

In young subjects consolidation, as a result of catarrhal pneumonia, may 
be met with at all parts of the lung. It is seen as often at the base as at 
the apex, both in front and behind. In all cases, therefore, it should be 
made a rule to search the chest completely before we allow ourselves to 
exclude the existence of a cheesy deposit. If this be done quietly and 
gently, as directed elsewhere (see page 13), the examination can usually 
be carried to a successful issue. In infants, as has been already remarked, 
phthisis may be present although but few symptoms of the disease have 
been noticed. The cough may be insignificant, the breathing quiet, and 
a looseness of the bowels of some standing may seem to explain sufficiently 
the pallor and wasting of the body and the distressed expression of the 
child's face. If, however, at the same time the evening temperature is 
higher than natural, the symptom is a suspicious one ; and if the state of 
the stools indicates the existence of ulceration of mucous membrane (see 
page 662), we must remember that this condition is often dependent upon 
chronic pulmonary mischief. In every case the physician, if he do his 
duty, will take nothing for granted, but will make systematic examination 
of all the organs of the body. 

A distinction between the catarrhal and tubercular forms of phthisis is 

readily made by comparing in each case the local signs with the general 

symptoms of the disease. Catarrhal phthisis, even when it begins at the 

apex by slow extension of the catarrhal process to the pulmonary alveoli, 

33 



514 DISEASE IN CHILDEEN. 

produces comparatively little impairment of the general nutrition of the 
body. The patient coughs and is a little feverish at night ; but his appe- 
tite is usually good ; his strength is little impaired ; and he retains a fair 
amount of flesh. Even when the progress of the disease has led to exten- 
sive consolidation of the lung, the marked contrast between the mildness 
of the general symptoms and the severity of the local signs discovered by 
physical examination, is sufficient to reveal the nature of the pulmonary 
mischief. In chronic tubercular phthisis the general symptoms are severe 
from the first. The child is pale and thin, feverish and languid, for some 
time before he is noticed to cough ; and it is still some time longer before 
examination of the chest discovers any positive indication that the lungs 
are the seat of pathological change. Moreover in catarrhal phthisis, until 
softening begins in the deposit, the disease is confined to one lung. In 
tubercular phthisis the physical signs, when they do present themselves, 
are discovered at both apices. 

On account of the frequency with which secondary attacks of sub-acute 
catarrhal pneumonia complicate cases of old consolidation, dilated bronchi 
are often present. These give rise to all the signs characteristic of excava- 
tion ; and it is very important to satisfy ourselves as to the nature of the 
pathological condition. Dilated bronchi are most common in the child at 
the base of the lung, while cavities are more frequently seated nearer to 
the apex. Therefore the situation of the signs at the base, although by no 
means conclusive evidence, points rather to bronchiectasis than to a vomica. 
Again, the general symptoms are of great importance. Dilated bronchi, 
unless occurring as a chronic condition in a case of fibroid induration of 
the lung, are met with towards the end of an attack of broncho-pneumonia. 
If then we find that, with the physical signs of a pulmonary cavity, the 
general condition of the child is improving ; that the temperature shows 
signs of falling ; the appetite improves, and the flesh and strength begin 
to return, the evidence is strong that the signs are not the consequence of 
ulcerative destruction of lung. Moreover, much assistance is to be de- 
rived from a microscopical examination of the sputum, where this can be 
obtained. In pulmonary ulceration areolar fibres of yellow elastic tissue 
will be seen in the muco-pus vomited or expectorated ; in cases of bron- 
chiectasis these will be absent. Lastly the progress of the signs will furnish 
corroborative evidence. Cavities tend to grow larger, dilated bronchi to 
contract. If, therefore, while the general symptoms remain stationary, the 
area over which the cavernous signs are heard is found to extend itself, we 
cannot but conclude that disorganisation of lung is advancing ; while if, 
with general improvement, the local signs diminish in intensity, our opinion 
that these are due to dilatation of bronchi receives additional confirmation. 

The distinction between pulmonary phthisis and fibroid induration of 
the lung is considered elsewhere (see page 478). 

Empyema is often confounded with phthisis ; and there is no doubt 
that the general appearance of a child the subject of old-standing purulent 
effusion is very like that of a consumptive patient. There may be the 
same hectic, the same emaciation, and the same weakness. In each case 
the child is irritable and restless with a hacking cough, some shortness of 
breath, a poor appetite, and a feeble digestion. On examination of the 
chest in each case we find dulness, often extensive, with perhaps loud 
cavernous breathing. But the history of the illness is very different in the 
two diseases. In pleurisy it begins with pain in the side followed after 
an interval by cough ; the dulness is complete with extreme sense of re- 
sistance ; it occupies both the front and back of the chest, unless the 



CHRONIC PULMONARY PHTHISIS — PROGNOSIS. 515 

empyema be loculated ; and reaches down to the extreme base. Moreover, 
the disease is strictly limited to one lung, the other being healthy ; and 
sighs of pressure are noticed ; the affected side is expanded ; the inter- 
costal spaces are less hollowed ; and the heart's apex is displaced. On 
the other hand, in a case of pulmonary phthisis sufficiently extensive to 
simulate a pleuritic effusion, the opposite lung will certainly show signs of 
disease. There will be no displacement of the heart or bulging of the 
side ; the dulness will not be complete ; the resistance to percussion will 
not be greatly exaggerated, if no great excess of fibroid tissue is present ; 
and the breath-sounds will be accompanied by a large-sized metallic 
gurgling rhonchus. In either case the vocal resonance will probably be 
bronchophonic ; but in empyema it often has an segophonic quality. 

Catarrhal phthisis in the young subject is very liable to be complicated 
by tuberculosis as a result of infection of the system by softening cheesy 
matter. The occurrence of tuberculosis is sometimes indicated by a rise 
of temperature and an increase in the rapidity of the breathing without 
any extension of the physical signs. Great irritability of the stomach and 
bowels is often induced ; the child vomits repeatedly, and the bowels are 
relaxed. Usually in these cases signs of intracranial irritation become 
quickly manifested ; and convulsions occur followed by squinting, ptosis, 
rigidity of joints, and other well-known signs of tubercular meningitis. 

Prognosis. — The gravity of the case in the two forms of pulmonary 
phthisis is very different. In an early stage of catarrhal phthisis we may 
reasonably hope, by putting the patient into the best sanitary conditions, 
to effect removal of the caseous consolidation. Absorption of a chronic 
solidification left after an attack of catarrhal pneumonia may be effected 
in the young subject after the lapse of many months ; and I have often 
seen cases in which signs of pneumonic phthisis occurring at the apex, 
from slow extension of a catarrh to the alveoli, have disappeared when the 
child has been sent to winter in a suitable climate. Indeed, if we can 
protect the patient from fresh chills, and secure for him an adequate 
supply of perfectly pure air — such conditions with good and sufficient 
food will do much to help him on his way to recovery. It is difficult to 
say at what period of time it becomes hopeless to expect absorption of a 
cheesy deposit. I believe that so long as no active change has taken place 
at the affected spot this fortunate termination to the case is still possible 
if the patient be a child. 

When a secondary catarrhal pneumonia occurs in a case of pneumonic 
phthisis the child will not necessarily die ; indeed, the acute attack usually 
runs a sub-acute course and is eventually recovered from. Still, the future 
prospects of the child are sensibly darkened by the addition usually made 
to the amount of previously existing disease by the passage of the com- 
plication. 

Cases of chronic tubercular phthisis always go on from bad to worse ; 
for although by a suitable climate and the careful avoidance of chills, at- 
tacks of catarrhal pneumonia may be prevented, the normal course of the 
tubercular disease is little affected by the treatment. 

In all cases, signs of very unfavourable import are : — Great rapidity of 
breathing, and signs of lividity ; a high evening temperature ; a red glazed 
tongue, with or without great disturbance of the stomach ; diarrhoea. The 
scrofulous constitution or a strong hereditary predisposition to phthisis is 
an element in the case of the utmost gravity. As far as is at present known, 
the quantity of the bacilli discovered in the sputa furnishes little informa- 
tion of importance in prognosis ; for these organisms are not found to be 



516 DISEASE IN CIIILDPwEN. 

necessarily most numerous in cases where the diseased processes are most 
active. 

Treatment. — Children born into families in which there is a consump- 
tive tendency require special care in their bringing up ; and every avail- 
able means should be adopted to counteract their unfortunate predisposi- 
tion. Infants should, if possible, be suckled by a healthy wet-nurse, and 
every precaution should be taken to ensure the purity of the air they 
breathe. As they grow, they should be accustomed to warm clothing, 
perfect cleanliness, and regularity of meals. Their food should be plain 
and well selected, avoiding excess of sweets and farinaceous matters, which 
are so apt to excite and maintain an acid condition of the alimentary canal. 
Their residence should be, if possible, on a dry soil and in a bracing air. 
If this be not practicable, they should at any rate be sent away to a more 
suitable habitation during the spring and fall of the year — times when 
the changeable season is so prejudicial to delicate children. They should 
be trained regularly to strengthen their muscles by out-door games ; and 
if the lungs are small, and the chest consequently narrow, every means 
should be resorted to to invigorate the pectoral muscles and expand the 
cavity of the chest. All forms of catarrh should be attended to with 
peculiar care, and the parents should be warned that neglect of such de- 
rangements may entail the most serious consequences. By such means a 
child naturally delicate may, as he grows up, appear to cast off many of 
the external signs of his constitutional tendency ; and although, no doubt, 
still exceptionally sensitive to unhealthy influences, may preserve his vigour 
under conditions which would quickly prove injurious to another less care- 
fully nurtured. A cold douche in the morning on rising from bed is of 
great service in these cases ; and if the shock is too great under ordinary 
conditions, the bath will be readily borne when given with the precautions 
recommended in a previous chapter (see page 17). 

If a child with such a tendency be attacked by measles or whooping- 
cough, the parents should be warned, as the disease subsides, of the dan- 
ger of neglecting the catarrhal complications which are so liable to occur 
in the later stages of these specific maladies. In every case where it is 
possible the patient should be sent for his convalescence to a good sea-side 
air. If catarrhal pneumonia have occurred, the clearing up of the consoli- 
dation must be carefully watched. Good ventilation and careful dieting 
are more than ever necessary ; and if absorption appear to flag, measures 
should be taken at once to alter the conditions under which the patient is 
living, and a change of air should be insisted upon. Alkalies and alkaline 
sprays are very useful in these cases, and the citrate of iron and quinine 
may be given with the citrate of potash with great advantage. 

In cases of acute phthisis energetic measures must be adopted. We 
should at once take steps to reduce the pyrexia, which is considerable, and 
to maintain the strength of the patient. Dr. McCall Anderson recommends 
the application of cold, either by iced cloths, Leiter's temperature regula- 
tors, or, if these means fail, by cold baths. He has found the application 
to the abdomen of cloths wrung out of ice-cold water and frequently re- 
newed, very useful in lowering the temperature, and speaks highly of Nie- 
meyer's combination of digitalis, quinine, and opium. I cannot myself say 
that I have seen much benefit result from this form of medication, but if 
thought desirable, half a grain each of the two former drugs may be given 
with an eighth or tenth of a grain of opium every four hours to a child of 
ten years old. Of other drugs, large doses of quinine seem to have only 
a temporary effect, and the salicylates in my hands have proved worse than 



CHRONIC PULMONARY PHTHISIS — TREATMENT. 517 

useless as anti-pyretics. They seem to exert little influence upon the tem- 
perature, while they irritate the stomach and cause nausea. Our chief re- 
source for reducing the temperature in this as in other forms of febrile 
disease, consists in the application of cold. 

In order to maintain the strength Dr. Anderson recommends hourly 
feeding, both day and night, with simple food, such as milk, broths, etc., 
and gives brandy or other stimulant as seems to be required. The profuse 
sweats must be controlled by the subcutaneous injection of atropine (gr. t %-q). l 
According to this author the most striking results may be sometimes ob- 
tained, and a complete cure occasionally effected by the above means. 

In the chronic forms of phthisis it is also of the utmost importance to 
improve the nutrition of the body. The absorption of recent deposits and 
the obsolescence of more chronic consolidations are best promoted by 
plenty of fresh air, the avoidance of chills, and a liberal supply of good 
food. In order, however, that the child may profit by an abundant dietary, 
it is essential that his digestive organs should be maintained in a high state 
of efficiency. The subjects of pulmonary phthisis resemble in one respect 
hand-fed infants. Like them they are liable to repeated attacks of gastro- 
intestinal catarrh, which gives rise to indigestion and flatulence. These 
attacks, by the influence they exercise upon general nutrition, may produce 
very serious consequences. If a child with disordered stomach be fed con- 
tinually with food which he has no means of digesting, not only is the 
gastric derangement protracted, but his system is kept in a state of fever 
which often culminates in a fresh attack of pneumonia. In any case, such 
a condition of the body is not calculated to encourage the healthy removal 
of morbid products. In all these attacks the diet should be at once al- 
tered. The child should take for food little but milk alkalinised with lime 
drops and diluted with barley water, weak broth, and dry toast. For medi- 
cine he may have an alkali with nux vomica to act as an antacid and stom- 
achic. By this means the gastric derangement will be quickly overcome. 

In all cases where the parents are in a position to afford the expense, a 
change of climate is of great service. A child who is the subject of an un- 
absorbed pneumonic deposit, whether this succeed to an attack of broncho- 
pneumonia, or have occurred more slowly from neglected catarrh, should 
change the conditions under which he has been living. If he reside at the 
sea-side, he should be sent inland ; if inland, he should be sent to the sea- 
side. A good sea voyage often brings about a complete cure in these cases. 
The body should be warmly clothed, the bed-room should be large, airy, 
and well ventilated, and the child should pass a large part of the day out 
of doors whenever the weather permits. Cod-liver oil is useful as a help 
to the treatment, but not as a substitute for it ; and iron and quinine with 
an alkali should be prescribed as already recommended. 

When softening begins at the seat of mischief and evident constitutional 
symptoms are observed, the child should be carefully protected from chills, 
and at the same time be insured a plentiful supply of fresh air. Mild 
counter-irritants should be applied to the chest over the diseased spot, 
such as painting with tincture of iodine or rubbing in a weak croton-oil lin- 
iment. The hypophosphite of lime (gr. iij.-v.) is of sensible value in these 
cases, and will often, when debility and weariness are complained of, cause 
an immediate improvement in the strength. In other cases arsenic is of 
great service, and may be given with quinine in doses of three to five 
minims of the arsenical solution three times a day. Lately iodoform has 
been recommended with the object of reducing secretion, moderating fever 
and cough, and arresting the progress of caseation. I have seen benefit 



518 DISEASE IN CHILDKEN. 

result from half-grain doses of the remedy given three times a day with 
extract of gentian. If the pyrexia is high, it may be reduced by sponging 
the surface with tepid water ; and night-sweats are usually readily con- 
trolled by one or two drops of the liq. atropine at bedtime given in a tea- 
spoonful of water. 

For some years, and especially since the discovery by Koch of the 
"tubercle bacillus," antiseptic inhalations have come greatly into favour. 
At night the air of the bed -room may be impregnated with the fumes of 
tar or creasote by Dr. J. E. Lee's ". steam-draught inhaler " or some similar 
instrument. In the day-time, by means of a perforated metal respirator, 
such as that devised by Dr. Coghill, of Ventnor, various antiseptic sub- 
stances may be inhaled for an hour at a time more or less frequently dur- 
ing the day. At the Victoria Park Hospital we have been in the habit of 
using for this purpose a preparation composed of two drachms each of the 
etherial tincture of iodine and carbolic acid, one drachm of creasote, and 
one ounce of rectified spirit. Of this ten drops are poured upon a piece 
of cotton wool and used in the respirator several times in the day. In 
many cases it is well to use the antiseptic frequently ; and if the child will 
submit to the inconvenience he may be made to wear the respirator all 
day long. In such a case the antiseptic drops can be renewed every two 
or three hours. Very good results are often obtained by the help of this 
method of medication. The violence of the cough is often diminished 
after the respirator has been worn for a short time, and the sputum is 
more readily brought away from the lungs. Expectorant mixtures will 
often have to be given in addition. The disadvantage of all these drugs, 
however, is their* unfortunate tendency to cause derangement of the 
stomach. When made use of it is advisable, if possible, to combine the 
expectorant with an alkali or a mineral acid. If the cough is hard and tight, 
a few drops of ipecacuanha wine should be given, with five or six grains of 
bi-carbonate of soda, in a draught sweetened with glycerine. Afterwards, 
when secretion is more copious, four or five drops of sal volatile may be 
combined with a drop or two of liq. morphi;p, or five to fifteen drops 
of paregoric, in glycerine and water. These may be followed by an alka- 
line and iron mixture, or a draught containing pernitrate of iron and dilute 
nitric acid. Cod-liver oil should always be given if it can be borne. "When 
this does not agree, maltine often proves a good substitute, and is usually 
taken readily by a child. 

In all cases the state of the digestive organs must be watched with the 
greatest vigilance, and any sign of acidity or flatulence must be a signal 
for a prompt reconsideration of the dietary. Pepsin is often useful given 
with dilute hydrochloric acid and strychnia, as recommended elsewhere 
(see page 641). If a difficulty is found in digesting starches, the liq. 
pepticus (Benger) given with an alkali about an hour after meals is of 
service. In such cases, also, the measures recommended for the treat- 
ment of chronic diarrhoea may be adopted with advantage (see page 640). 

If the cough excite vomiting, this symptom can be generally allayed by 
the administration of one drop of Fowler's solution of arsenic before a 
meal ; or half a drop of liq. strychnia^ often has an equally beneficial action. 
If haemoptysis occur, the child should be kept perfectly quiet in bed ; fluids 
should be given to him in small quantities at a time, and he may take fif- 
teen to twenty drops of the liquid extract of ergot with mildly aperient doses 
of Epsom salts three times a day. If, however, the bowels are ulcerated, 
the saline laxative must be omitted. Diarrhoea dependent upon this in- 
testinal lesion must be treated as recommended elsewhere (see page 666). 



CHAPTER XIII. 

PAROXYSMAL DYSPNCEA. 

Dyspncea is a symptom frequently met with in early life. The term does 
not denote merely increased rapidity of breathing. The respiratory move- 
ments may be hurried without the patient's being sensible of any unusual 
effort in the act of breathing or of suffering from imperfect aeration of the 
blood. To constitute dyspnoea there must be perceptible distress ; and the 
term may be defined as a conscious embarrassment in the performance of 
the respiratory function. 

Dyspncea is by no means confined to cases of pulmonary mischief ; in- 
deed, in the child, extreme difficulty and labour of breathing, with great 
lividity of face, although possibly produced by disease of the lung, is yet 
more commonly the consequence of some other cause. The most urgent 
and alarming form of dyspnoea is seen in cases of impediment to the pas- 
sage of air through the glottis. We find it carried to its highest point in 
stridulous and membranous laryngitis, in obstruction of the windpipe by 
a foreign body, in extra laryngeal pressure from an abscess in the pharynx, 
and in pressure upon the trachea or a large bronchus by a mass of enlarged 
glands. Again, intense dyspnoea may be found in a case where ah- pene- 
trates freely into the lungs. If the circulation through the pulmonary 
vessels is obstructed, as when a clot is slowly forming in the pulmonary 
artery, the suffering from deficient aeration of blood may amount to an 
agony. So, also, in serious disease of the heart dyspnoea is a common 
symptom, for the passage of blood through the lungs is impeded by the 
valvular lesion. 

Again, external pressure upon the lung will excite a very pronounced 
feeling of dyspnoea. When one lung is entirely compressed, and the heart 
dislocated by a copious liquid effusion into the pleura, dyspnoea may be 
urgent and threaten actual suffocation. When the ribs are greatly soft- 
ened, as in a case of advanced rickets, the pressure of the atmosphere upon 
the yielding chest-walls may cause such impediment to the expansion of the 
lungs that serious dyspnoea may be induced. If at the same time the de- 
scent of the diaphragm is impeded by accumulation of flatus in the belly, 
the danger is really imminent. On the other hand, in cases of actual pul- 
monary mischief dyspnoea is not always present. We find it, indeed, in 
catarrhal pneumonia and bronchitis, especially if the latter disease is ac- 
companied by any occlusion of the tubes ; but in other cases of interfer- 
ence with the pulmonary function it is exceptional to see signs of suffering 
from conscious want of air carried to an extreme degree. Even in ad- 
vanced phthisis distress from this cause is rarely great ; and in croupous 
pneumonia and collapse of the lung the respirations, although greatly 
quickened, are accompanied by little or no exaggeration of movement, and 
dyspnoea in the sense of an active feeling of oppression of the chest cannot 
be said to exist. 



520 DISEASE IN CHILDBED. 

In every case of dyspnoea we have, therefore, to examine very carefully 
in order to discover the cause to which the impediment to respiration may 
be correctly attributed. As a rule, perhaps, dyspnoea is irregular in its 
severity. It is subject to temporary increase and diminution, so that the 
patient from a condition of great distress may pass into a state of com- 
parative ease. The term "paroxysmal dyspnoea " is, however, confined to 
cases where the difficulty of breathing occurs in attacks of variable sever- 
ity, which last a longer or shorter time and then pass completely away. 

There are certain rare causes of remittent dyspnoea in the child which 
may be mentioned. These are — paralysis of the respiratory muscles and of 
the diaphragm, such as may occur as a sequel of diphtheria (see page 100) ; 
interstitial oedema of the lung from acute Blight's disease (see page 39) ; 
and clotting of blood in the pulmonary artery (see page 98). These lesions 
are, however, exceptional, and the dyspnoea they induce is not paroxysmal 
in the correct sense of the word ; for although the feeling of suffocation 
moderates, it does not entirely subside. 

As commonly met with in the child, paroxysmal dyspnoea, i.e., dyspnoea 
occurring in paroxysms with intervals of complete intermission, is a result 
of the following causes : 

Stridulous laryngitis. 

Pressure upon the trachea or a large bronchus by swollen bronchial 
glands. 

Obstruction of a bronchus by a foreign body. 

True bronchial asthma, occurring often in the course of chronic bron- 
chitis and emphysema. 

Of these the first-named disease is fully considered elsewhere. It re- 
quires no further notice in this place, as the severity of the laryngeal symp- 
toms at once indicates the seat of the impedient to respiration. The other 
forms of paroxysmal dyspnoea are often confounded together under the 
common name of " asthmatic attacks." Dyspnoea arising from the press- 
ure of enlarged bronchial glands and the difficulty of breathing induced 
by the presence of a foreign body in the air-tubes are described in other 
parts of this treatise. They will, however, be again referred to in discuss- 
ing the diagnosis of asthma. 

Bronchial asthma is comparatively seldom met with in the child. "When 
it occurs at this period of life, it appears to be almost invariably the con- 
sequence of whooping-cough or catarrhal pneumonia. The seizures always 
assume the "catarrhal form ;" indeed, the subjects of the disease are 
usually sufferers from emphysema of the lungs, and the attack of dyspnoea 
occurs as a consequence of a fresh catarrh. In many cases the child comes 
of a gouty family, and sometimes the pulmonary disease appears to be 
hereditary. The tendency to asthma is occasionally associated with a ten- 
dency to general eczematous eruption ; and Dr. West states that he has 
never known eczema to be very extensive and very long continued without 
a marked liability to asthma being associated with it. The two affections 
may alternate — the one subsiding when the other appears — as in the case 
of a boy of six years old referred to by Caillaut ; but they may be also co- 
existent, and the cure of the one is often followed by the disappearance 
of the other. 

The exciting causes of the attack appear to be in most cases the inhala- 
tion of some irritating matters, either in fine dust or vapour, directly into 
the air-tubes. A paroxysm sometimes follows an indigestible meal, or is 
induced by food imperfectly masticated and hurriedly swallowed. It has 
been consequently suggested that irritation of the gastric filaments of the 



PAROXYSMAL DYSPNOEA — BEOJSTCHIAL ASTHMA. 521 

pneumogastric may be reflected to the pulmonary brandies of the nerve, 
and through them set up spasm of the tubes. But the theory of reflex 
action is surely exposed to a severe strain by such an explanation. 

Without expressing any opinion upon the vexed question of the nature 
of the asthmatic seizure — whether it be a pure neurosis (as is commonly 
held) or not — I may observe that it is at least curious that in children, 
whose tendency to nervous spasm of every kind is one of the physiological 
peculiarities of early life, pure asthma should be an affection so rarely met 
with ; that while general convulsions may be induced by peripheral irrita- 
tion of various degrees of severity, while spasmodic contraction of the 
glottis may be set up by a trifling laryngeal catarrh, an attack of paroxys- 
mal dyspnoea from spasmodic occlusion of the smaller air-tubes should be 
a phenomenon of such infrequent occurrence. That it is extremely rare 
there can be no doubt. Of the recorded cases of asthma in young children 
there are very few in which direct pressure upon the bifurcation of the 
trachea or a main bronchus by enlarged bronchial glands can be excluded. 
I have seen many cases of so-called asthma in the child, but have rarely 
failed to find evidence of swelling— often of considerable swelling — of these 
glands. 

Symptoms. — Asthmatic children, as has been said, are usually the sub- 
jects of emphysema. This condition often gives little evidence of its pres- 
ence until the lungs are attacked by a fresh catarrh. The breathing then 
becomes excessively oppressed, so that the child is unable to lie down in 
his bed. The face is pale, with a dusky tint round the mouth and eyes ; the 
eyes are staring and congested ; the mouth is open ; the lips are purple ; the 
nostrils work violently, and the forehead is covered with beads of sweat. 
The child is very restless, throwing about his arms, and his face expresses 
great suffering. His heart acts violently and irregularly, but the pulse w 
small and weak. When the chest is uncovered, all the respiratory muscle* 
are seen to be in action, but the chest remains fully distended and move * 
but slightly at each breath. There is little hurry of breathing on accoun 
of the increased length of expiration, and the temperature is not elevated 
The cough is usually short and dry, but not at all paroxysmal. 

On examination of the chest during an attack we find general hyper- 
resonance of the percussion note ; the vesicular murmur is either very fee- 
ble or completely suppressed, and is often quite covered by large sonoro- 
sibilant rhonchus. At the base copious subcrepitant rales may be heard. 

The attack lasts for a variable time. It usually continues more or less 
severely for two or three days, and then gradually subsides. As a rule, the 
more severe the dyspnoea, the shorter its duration ; but for days or even 
weeks after the attack is over the child may wake up wheezing in the morn- 
ing, and his breath may be short for some hours after rising from his 
bed. 

Sometimes the onset of the attack is heralded by severe coryza, with re- 
peated sneezing, and this is quickly followed by distressing dyspnoea. The 
oppression of breathing seems sometimes to threaten actual suffocation and 
in all cases the severity of the suffering from want of air is out of all pro- 
portion to the insignificant character of the physical signs. The seizure, 
however, invariably ends in recovery. After a time the. breathing becomes 
easier, and eventually all distress is at an end ; but before the termination 
of the attack is reached there may be many alternations in the intensity of 
the dyspnoea, and even after the days have become peaceful the nights 
may still be disturbed by a return of the paroxysms. 

Diagnosis. — In cases of paroxysmal dyspnoea it is important with regard 



522 DISEASE IN CHILDREN. 

both to prognosis and treatment to ascertain the exact cause of the dis- 
tressing symptom. 

When the dyspnoea is due to occlusion of the larynx from spasm, from 
impaction of a foreign body, or from the pressure of a retro-pharyngeal 
abscess, the difficulty lies chiefly in inspiration. As each breath is drawn 
the soft parts of the chest sink in and the epigastrium is deeply retracted. 
The inspiration is excessively long and laborious, the expiration short and 
comparatively easy. At the same time crowing sounds are produced in the 
glottis and point unmistakably to the seat of the impediment. 

In cases where the hindrance to respiration is seated at a lower level, 
as when a main bronchus is obstructed by a foreign body, or the trachea 
at its bifurcation is compressed by a mass of swollen glands, and also in 
cases of bronchial asthma, the distress is chiefly seen in expiration, which 
is prolonged, laborious, and ineffectual. Attacks of dyspnoea from these 
causes require to be very carefully discriminated, as they are all commonly 
spoken of as " asthmatic attacks." The most frequent of these in children, 
beyond all comparison, is enlargement of the bronchial glands ; and most 
cases of " asthma " in early life are due to direct pressure by swollen glands 
upon the air-tubes. Scrofulous children are very sensitive to chills and 
readily take cold. They are consequently frequent sufferers from pulmo- 
nary catarrh. In these attacks the glands undergo a rapid temporary in- 
crease in size, and their enlargement may set up serious pressure upon the 
windpipe at its bifurcation. 

Dyspnoea from this cause is often intense, and comes on in violent par- 
oxysms which usually occur at night. The character of these seizures has 
been elsewhere described (see page 182). In such cases there is not al- 
ways dulness at the upper part of the sternum, or between the scapulae ; 
for alteration of the percussion-note can only be noticed in cases where the 
swollen glands are in contact with some part of the chest-wall. The chief 
collection of bronchial glands lies in the bifurcation of the trachea ; but 
others are distributed along the course of the bronchi as far as the third or 
fourth subdivisions. Enlarged glands, therefore, may be found after death 
deep in the substance of the lung, as described by Cruveilhier. The effect 
of enlargement of these bodies is to press upon and flatten the air-passages ; 
and if the calibre of the tube be at the same time lessened by viscid secre- 
tion, the channel for the time may be completely occluded. By such means 
the most serious dyspnoea may be produced. 

A little girl, between three and four years old, was said to be subject to 
feverish attacks which lasted from a few days to a week. In these the child 
first showed symptoms of catarrh and then began to suffer from urgent 
dyspnoea. In the last of these attacks, as described to me, the breathless- 
ness began quite suddenly at night and woke the child up from her sleep. 
She was said to have started up gasping in the utmost distress, and her 
voice was hoarse. After about an hour the paroxysm subsided and the 
child had a violent attack of spasmodic cough, retching up much phlegm. 
The seizures were repeated for six nights in succession, becoming, how- 
ever, less severe towards the end of this period. In the daytime the pa- 
tient seemed fairly well, although towards evening her breathing would be 
a little short. Her nose also bled a great deal. This little girl was brought 
to me some time after the last attack had subsided, when she had returned 
to her usual health. The jugular veins on each side of the neck were then 
noticed to be full, and the venous radicles on the front of the chest to be 
unnaturally visible. There was a suspicion of dulness on the upper bone 
of the sternum, and when the child bent her head backwards a venous hum 



PAEOXYSMAL DYSPNCEA — DIAGNOSIS. 523 

was heard at that spot, ceasing when the chin was again depressed. The 
lungs did not appear to be emphysematous, nor was there any dulness at 
either apex ; but the breath-sounds were very loud and hollow at the su- 
pra-spinous fossae, especially in expiration. 

There can be little doubt that this child was suffering from enlarge- 
ment of the bronchial glands. The character of the attacks, accompanied 
by hoarseness of the voice, the bleeding from the nose, the fulness of 
the jugular in the neck and of the superficial veins of the chest, the 
hollow breathing at the apices without sign of disease of lung, and the 
venous hum heard at the upper part of the sternum when the head was 
retracted — indicating some pressure set up in that position upon the left 
innominate vein —all these signs were very suggestive of glandular enlarge- 
ment. The child had a scrofulous appearance and was living in a cold, 
damp situation. She was treated with iodide of iron and cod-liver oil, and 
was sent to pass the winter at Bournemouth, whence she returned greatly 
improved. 

This subject of glandular enlargement in the mediastinum has been 
already considered in another place. The reader is therefore referred to 
the chapter on scrofula for fuller details with regard to the phenomena 
produced by the lesion and the signs by which its presence may be ascer- 
tained (see pages 182 and 183). 

The intrusion of a foreign substance into the bronchus is sometimes a 
cause of paroxj'smal dyspnoea. This accident may be suspected if a first 
attack come on quite suddenly at or shortly after a meal, or under circum- 
stances which justify the assumption, as when a child is playing with small 
objects which might readily slip into the larynx. In such a case, if the ob- 
ject be a small one, the breathing is not always affected at once ; and if 
some cough and discomfort are excited at the first, these symptoms almost 
invariably subside, to return after a longer or shorter interval. Professor 
Henoch has reported the case of a girl, aged nine years, who went to bed 
apparently in good health, but was restless, complaining of discomfort 
during the night. Towards the morning she was seized with extreme dysp- 
noea and cyanosis. The child was taken to the hospital, where no signs 
of pulmonary disease could be detected. Shortly after her return home 
she began to vomit large quantities of undigested food, amongst which 
were found pieces of a hard-boiled egg which she had hurriedly swallowed 
on the previous evening. When the vomiting had subsided the girl had a 
good night's rest and the dyspnoea did not return. In this case Dr. Henoch 
attributed the dyspnoea to irritation of the gastric filaments of the vagus ; 
but it seems more probable, as Dr. Birkart has suggested, that the symp- 
toms were due to actual bronchial obstruction by a portion of the imper- 
fectly masticated food. The ordinary symptoms produced by the presence 
in the air-tubes of a foreign substance, and the means by which the cause 
of the dyspnoea may be recognised, are treated of more fully in another 
chapter (see page 527). 

The diagnosis of bronchial asthma has usually to be made by exclu- 
sion, no other cause being found to which the access of dyspnoea can be 
attributed. When called to a child who is said to be suffering from 
attacks of severe dyspnoea, unaccompanied by laryngeal stridor, we should 
first of all suspect the presence of enlarged bronchial glands. If the most 
careful examination fails to detect the existence of any such lesion ; if we 
find that in the interval of such attacks the child is well and hearty, with- 
out albuminuria or sign of disease of the heart ; that the seizures came on 
under the influence of a pulmonary catarrh ; and that the only physical 



524 DISEASE IN CHILDREN. 

signs discoverable consist in a certain hyper-resonance of the percussion- 
note with an occasional click or coo of rhonchus, we may conclude that 
we have to do with a case of bronchial asthma. 

Prognosis. — If the child be in such a position in life that proper meas- 
ures can be taken for his relief, his prospects are not unfavourable. If he 
can be sent away to a proper climate, be warmly dressed and carefully 
attended to, dyspnoea from enlarged bronchial glands or from bronchial 
asthma is usually recovered from. The most serious forms of paroxysmal 
dyspnoea are those which result from the presence of a foreign body in 
the air-passages ; from interstitial pulmonary oedema in Bright's disease ; 
and from clotting in the pulmonary artery. In the last of these, few cases 
recover. In the case of Bright's disease when the illness is of the acute 
form, we may have hopes that if the immediate danger can be tided over, 
the child may eventually recover. If the renal mischief be chronic, the 
prognosis is very unfavourable. When the dyspnoea is due to the entrance 
of a foreign body into the air-passages, the prognosis is given elsewhere 
(see page 533). 

Treatment. — If the child be first seen during an attack we are forced 
to treat the dyspnoea without reference to its cause. Strong mustard 
poultice should be applied to the chest and moved about from one place 
to another over the front and back of the thorax. Secretion should be 
promoted by giving hot liquids to drink ; and a very useful form is that 
composed of a dessert-spoonful of liq. ammonise acetatis, diluted with three 
or four times its bulk of hot water. Trousseau recommends the burning 
of stramonium leaves in the room ; but this is a very uncertain remedy 
and has lately fallen out of favour in the case of the adult. The fumes of 
nitre paper are preferred by some. Enough should be used to make the 
atmosphere thick with the nitrous vapour. If we can discover that the 
child has lately swallowed some indigestible food or notice any undue 
distention of the abdomen, it will be well to relieve the stomach by an 
emetic dose of ipecacuanha wine. 

When the attack of dyspnoea has subsided or the respiration has 
become easier, we shall be probably able to examine the patient sufficient- 
ly to form an opinion as to the cause of the distress in breathing. When 
the dyspnoea is due to enlargement of the bronchial glands, or to any of 
the less common causes which have been mentioned, the general treatment 
to be pursued is described in other parts of this treatise. 

If the case be one of bronchial asthma the child is almost invariably 
the subject of pulmonary emphysema, and the treatment recommended 
for that condition of the lung should be scrupulously carried out. All 
means which invigorate the general health are useful, and cod-liver oil 
with iron, especially the iodide of iron, should be prescribed. Fowler's solu- 
tion of arsenic is also often of service, especially in cases where the asth- 
matic symptoms are associated with eczema of the scalp or other part of 
the body. Dr. Thorowgood advocates the use of a tonic during the day, 
and recommends a sedative at night, such as a dose of the extract of 
stramonium or tincture of belladonna. Thus, a child of six years old may 
take three or four drops of the liq. arsenicalis with ten of the tincture of 
perchloride of iron freely diluted after each meal, and on going to bed 
twenty to thirty drops of the tincture of belladonna. 

The hypodermic injection of pilocarpine may be used in these cases, as 
directed by Dr. Berkart. Children bear this remedy well. For a child of 
five years old, gr. -J^ to gr. -^- may be injected under the skin when the child 
is put to bed. In the daytime the arsenic and iron can be continued. 



PAROXYSMAL DYSPNCEA — TREATMENT. 5-25 

When the attacks of dyspnoea come on chiefly at night, the child should 
be forbidden to eat heartily in the latter part of the day, and should by 
no means be permitted to go to bed shortly after a full meal. Indeed, care 
should be taken at every meal that the stomach is not overloaded, and Dr. 
Thorowgood's caution that moderation should be exercised in the use of 
farinaceous and saccharine articles is especially wise in the case of a child. 

The whole secret of the treatment of these cases consists in employing 
all available measures for improving the general strength and in guarding 
the patient carefully from chills. Exercise, gymnastics, and games wmich 
further the development of the muscles and promote the action of the skin 
are all very useful. 



CHAPTER XIV. 

FOREIGN BODIES IN THE AIR-TUBES. 

The passage of solid substances into the air-tubes is a far from uncommon 
accident and one to which children, for obvious reasons, are peculiarly 
liable. Articles of the most varied description have been inadvertently 
drawn into the trachea, and their retention in the bronchi may not only 
produce the most serious distress but set up profound disorganization in 
the affected lung. 

Fruit-stones, as might be expected, are perhaps the commonest things 
to make their way into the trachea ; also peas, beans, grains of corn, vari- 
ous seeds, bits of solid food, fish-bones, portions of nut-shell, and any 
small articles which lie about in a room or can be picked up from the floor, 
such as little coins, tin tacks, dress-hooks, buttons — all of these objects, 
and many others, have been known to pass between the vocal cords and 
be imprisoned in a bronchus. It is at first difficult to understand how a 
substance as large as a plum- or date-stone can pass through the narrow 
aperture formed by the vocal cords in a young child. It must be remem- 
bered, however, that when the chest-walls are expanded in the act of inspi- 
ration, if a solid body is drawn into the opening, a very strong pressure 
from the external atmosphere forces it onwards, while resistance is very 
trifling on account of the tendency to form a vacuum inside the chest. 
Consequently, the substance is driven through the opening with consider- 
able force. 

Morbid Anatomy. — The morbid changes which result from the presence 
of a foreign substance in the air-passages are often very extensive. The 
immediate consequences are congestion and irritation of the mucous mem- 
brane lining the trachea, and if the substance is small enough to penetrate 
into them, of the bronchi. Secretion then takes place of a thin frothy 
fluid which soon becomes purulent, and may be so profuse that after death 
the air-tubes are found filled with yellow puriform matter. Thick lymph 
may be also thrown out so as partly to coat the obstruction. In a case re- 
corded by Mr. Bullock the lymph became organized into fibrinous casts 
and almost closed the upper portion of the windpipe. The muco-pus is 
thick and ropy and in long-standing cases may be inexpressibly fetid. 

A substance capable of passing into the larger bronchi soon sets up 
inflammation in the lung. The inflammation may be limited to one lobe 
or may spread to the entire organ. Sometimes both lungs are affected 
simultaneously, owing to the offending substance being dislodged by the 
repeated cough and falling back into one or the other bronchus indiscrim- 
inately. The affected part becomes consolidated, and if the irritation per- 
sist, soon disintegrates and breaks down. Cavities are thus produced 
which are filled with offensive and even gangrenous debris and much puru- 
lent matter. If there be no sufficient communication with an air-passage, 
the contents may be retained; but usually an opening becomes established 



FOREIGN BODIES IX THE AIR-TUBES— SYMPTOMS. 527 

with the bronchus and much fetid matter is expectorated. In scrofulous 
or tubercular subjects gray granulations may be developed in the hepatized 
tissue arouucf the cavity, and it has happened that the child has died from 
general tuberculosis. The bronchial glands also become enlarged and 
cheesy. 

Besides pneumonia, other pulmonary lesions may be present. More or 
less emphysema is usually produced, and collapse of portions of the lung 
may occur. The inflammatory action may not be confined to the luno-. 
Empyema is a common consequence of the presence of the irritant ; and 
enormous quantities of purulent fluid have been found distending the 
pleural cavity. Pericarditis has also been known to occur, and in a case 
recorded by Mr. Solly a large abscess had formed in the mediastinum as a 
consequence of the pericardial inflammation. Sometimes the abscess of the 
lung becomes adherent to the chest-wall and points in an intercostal space 
or elsewhere. Dr. Wilts has referred to a case in which an ear of corn es- 
caped in this manner from an abscess which had formed in the supra- 
scapular region ; and other cases of a similar kind are on record. 

Symptoms. — The irritation produced by the entrance of a foreign body 
into the trachea and bronchi varies greatly in different patients. Although 
in the majority of cases the suffering is extreme, in a few instances curiously 
little discomfort appears to be excited. It is important to be aware that 
violent dyspnoea is not an unfailing symptom of this accident. In some 
recorded cases a little cough has been the only inconvenience complained 
of. Dr. Goodheart has stated that on two occasions in his experience in 
which dissection revealed gangrene of the lung setup by a spicula of bone 
in one of the bronchi no symptoms had been noted during life pointing to 
the entrance of a foreign substance into the air-tubes ; and thence con- 
cludes that pulmonary disease is more often excited by this mischance than 
is commonly supposed. 

Still, although in exceptional cases the suffering may be slight, as a 
rule the intrusion of any adventitious matter into the wind-pipe is a cause 
of immediate and extreme distress. If the substance be of large size it may 
completely occlude the glottis and cause sudden death. Many cases are 
on record in which the entrance of the wind-pipe has been blocked up by 
a lump of food with immediately fatal results. Smaller bodies which can 
pass readily into the air-tubes, if not arrested at the bifurcation of the tra- 
chea, fall as a rule into the right bronchus. Mr. Goodall of Dublin pointed 
out many years ago that the septum of the division of the windpipe is 
placed considerably to the left of the mesial line, and that this position 
tends to deflect any substance falling against it into the light division of 
the air- tub 9. 

The first consequence of the accident is usually a fit of severe dyspnoea 
with sense of impending suffocation. The child shows all the symptoms 
of the most extreme distress. His eyes look wild ; his face is livid ; his 
nares work ; his chest heaves convulsively ; he tears with his hand at his 
throat, and bursts into a paroxysm of spasmodic cough. As a rule ex- 
piration seems more difficult than inspiration, and the effort to discharge 
air from the lungs is laborious and painful. In some cases foam tinged 
with blood appears at the lips. The early symptoms are more severe if 
the object lodges sufficiently near to the glottis to keep up irritation of 
the vocal cords. The attacks of spasmodic cough are then almost inces- 
sant and the difficulty of breathing extreme. In ordinary cases after some 
minutes the more urgent symptoms abate and may entirely subside, so 
that the child who a short time before had seemed on the very point of 



528 DISEASE IN CHILDEEN. 

suffocation returns to his play as if nothing had happened ; but after a 
period of calm the paroxysms usually return with more or less violence. 
The period of repose which follows the first access of dyspnoea is of very 
variable duration. It may last from a few minutes to several hours ; and 
cases have been published in which no return of the distress was experi- 
enced for many months. The degree of suffering in these cases, accord- 
ing to Dr. Stokes, is dependent to a considerable extent upon the com- 
pleteness with which the intruding body interferes with the passage of air 
through the tube. He states that in all cases which have come under his 
own observation the distress was great in proportion to the feebleness of 
respiratory murmur in the affected lung. A smooth body, therefore, such 
as a bean, by completely occluding the tube causes greater suffering than 
a more irregular substance will do ; for the latter, although it obstructs 
the passage, does not render it absolutely impermeable. 

Often in addition to recurring attacks of dyspnoea and spasmodic 
cough there is a fixed pain or soreness referred to the throat or some part 
of the chest, back, or side. This sensation is probably dependent upon 
the impaction of the intruding substance in some particular part of the 
bronchus, for it has been known suddenly to shift its place, passing from 
the throat to the chest or to the region of the nipple. In some cases the 
pain is accompanied by a sense of constriction. Often, also, there is ina- 
bility to lie on one or the other side, such a position increasing the uneasy 
feeling and impeding the respiration. Sometimes the child can only 
breathe with ease in the sitting position, and has to be propped up in bed 
with pillows. The fits of coughing are of a peculiar character. They are 
usually excessively spasmodic and often resemble the cough of pertussis. 
They are accompanied by much congestion and lividity of the face, but 
are not followed by attempts to vomit. Sometimes the paroxysms are so 
violent as to lead to a convulsive seizure. If the object introduced is a 
fruit-stone or similar solid substance, and is free to move in the air-pas- 
sages, the cough may be accompanied by a peculiar clicking or flapping 
noise heard in the direction of the larynx, and produced apparently by 
the impact of the object driven upwards against the glottis by the current 
of air. In many cases the impact may be felt as well as heard if the finger 
and thumb be applied during the cough to opposite sides of the larynx. 

The voice may be unaltered unless the object be arrested in the neigh- 
bourhood of the glottis, as in one of the ventricles of the larynx, in which 
case there may be any degree of hoarseness even to complete aphonia. 

On inspection of the chest considerable recession of the soft parts is 
usually to be noticed in inspiration, and there may be a swelling of the 
neck and upper part of the chest from surgical emphysema. Often a phy- 
sical examination at an early period detects little or no deviation from a 
healthy state. There may be perfect resonance ; the respiration may be 
normal, and nothing may be heard but a little sonorous or sibilant rhon- 
chus over the lung in connection with the occluded bronchus. If the 
foreign substance be impacted and immovable in the air-tube, signs of 
collapse may be noticed at some part of the lung a few days after the ac- 
cident ; or there may be absolute suppression of the respiratory murmur 
over the whole of the affected side. 

Whenever irritation is excited in the air-passages there is fever, and 
the general health of the child necessarily suffers from the constant dis- 
tress and interference with sleep. Food can, however, be taken without 
difficulty. 

In some cases after a few hours or a day or two a spontaneous expul- 



FOREIGN BODIES IN THE AIR-TUBES — SYMPTOMS. 529 

sion of the offending substance takes place during a fit of coughing and 
the patient is instantly relieved. If, however, the child is less fortunate 
and the foreign body remains in the tubes, its presence being unknown or 
efforts to procure its removal having proved fruitless, serious consequences 
ensue. The object may become impacted in the larynx, causing death by 
suffocation ; it may set up a violent catarrhal pneumonia and the patient 
may quickly die ; it may give rise to suppuration and gangrene ; or it may 
lead to chronic phthisis which ends fatally after a more or less lingering 
illness. 

Spontaneous expulsion usually takes place, as has been said, during a 
violent fit of coughing. It may occur after a short or a long interval ; and 
in some cases a period of years has elapsed before the offending substance 
has been ejected. The completeness of recovery in such cases depends 
upon the degree to which the lung has suffered from the presence of the 
intruder. If the foreign body have only given rise to irritation in the lung, 
its removal is followed by instant and permanent relief. If, however, pneu- 
monia have been set up, or an abscess have formed, or chronic phthisical 
changes have been induced, the patient may die, although the original 
cause of his suffering has disappeared. 

In cases where the foreign body remains in the tubes, a constant source 
of irritation and of interference with the function of the affected organ, the 
physical signs depend upon the form of lesion which is produced. In some 
cases profound disorganization of the lung follows, and extra-costal sup- 
puration may be set up leading to the formation of a large superficial ab- 
scess. 

A little boy, aged seven years, whose family history showed no tendency 
to phthisis, was in his usual health when, on March 28th, he returned from 
school saying he had swallowed a date-stone. He complained of difficulty of 
breathing and pain in the side, and coughed a great deal. The symptoms 
apparently were not very severe, for the child was only brought to the hos- 
pital on April 8th. On his admission it was noted : " Much recession of 
the lower parts of the chest on inspiration ; intercostal spaces move equally 
on the two sides. Resonance good over both sides, but on the left the inspi- 
ration is everywhere high-pitched and bronchial, and is as loud below T as 
above. No rhonchus or friction. Heart's apex between the fifth and sixth 
ribs just outside the nipple line. A faint double friction-sound at the base 
of the heart and a soft systolic murmur at the apex." 

At this time nothing- was known of the accident ; and as there was but 
little oppression of breathing and the cough soon after admission was found 
to be spasmodic, the boy was thought to be developing whooping-cough 
and was sent out by the House Surgeon. 

On April 22d, the child was brought back to the hospital with a full 
account of the origin of the illness. It was stated that after his discharge 
he had continued to cough in a spasmodic manner and to whoop occasion- 
ally. He had often complained of pain in his stomach and left side and 
his breathing had been oppressed. He had little appetite. His skin had 
been hot with occasional perspirations. Shortly before his return to the 
hospital the aspirator had been used to the chest by a practitioner of the 
neighbourhood, but no fluid had escaped. 

The boy appeared to be excessively ill. He complained much of pain 
in the abdomen and lay with his knees drawn up. The abdominal pari- 
ties were somewhat retracted. Over the left back reaching from the poste- 
rior axillary line nearly to the spine, and from a little above the lower 
angle of the scapula to the tenth rib, was a large superficial collection of 
34 



530 DISEASE IN CHILDREN. 

matter. This on being opened was found to consist of very offensive pus. 
The abscess evidently communicated with the pleural cavity, for air was 
sucked in through the wound at each inspiration. The boy's breathing 
was laboured and his voice whispering. An examination of the chest was 
difficult on account of the tenderness of the side. It was however, ascer- 
tained that resonance of the left back, although impaired, was not quite 
lost, and that the respiratory sounds were concealed by loud creaking and 
gurgling rhonchus. 

The boy remained very prostrate and in great distress. He was exces- 
sively restless and occasionally screamed in a very hoarse voice. The 
discharge from the wound was inexpressibly fetid. He died on April 
25th. His temperature after readmission varied between 100° and 102.4°. 

On examination of the body, seventeen hours after death, the super- 
ficial abscess cavity was found to extend from the middle line of the right 
clavicle across the chest and round the left side to the spine. The skin 
over it was sodden and seemed almost decomposed. The body was much 
emaciated. On opening the chest the right lung was generally adherent 
to the chest-wall, although not very firmly. Its substance was somewhat 
congested but otherwise normal. The bronchi were injected and their 
mucous lining cedematous. 

The left lung, firmly adherent on its posterior surface, was extensively 
disorganized. Its substance tore easily and the smell was almost insup- 
portable. The surface of the diaphragm had the appearance of an abscess. 
In the eighth interspace, about one inch behind the posterior axillary line, 
was a large ulcerated depression rather more than an inch in diameter, 
at the bottom of which was a perforation communicating through the 
intercostal space with the superficial abscess. The trachea was injected, 
and in the left bronchus was a date-stone impacted about an inch and a 
half from the bifurcation. The lining membrane of the bronchus was red 
and cedematous, but the air-passages contained no excess of fluid. On 
account of the disorganized state of the lung it was impossible to say 
whether an abscess had originally formed in the neighbourhood of the 
date-stone. There was no peritonitis. The left ventricle of the heart 
was hypertrophied, and the edges of the mitral valve were much thick- 
ened. 

This case is peculiar on account of the situation of the foreign body, 
which had passed into the left bronchus instead of the right. "When the 
child was first brought to the hospital no mention was made of his acci- 
dent, and nothing in his symptoms suggested the presence of a solid 
substance in his lung. There was no great distress of breathing, and the 
physical signs, such as they were, were limited to the left lung, the right 
side of the chest being healthy. 

The foreign body after passing the rima glottidis may be caught in 
one of the ventricles of the larynx ; it may become fixed in the trachea ; 
or may pass further down and lodge in one of the primary divisions of the 
air- tube. There are, therefore, certain varieties in the symptoms according 
to the position of the obstruction. 

If the solid substance remain in the larynx, the voice is suppressed ; 
the dyspnoea is continuous ; the cough is generally violent and croupy ; 
the child feels as if he should choke ; and there is often pain referred to 
the situation of the cricoid cartilage. It may, however, be remarked that 
aphonia is not limited to these cases, and that a hoarse whispering voice 
does not necessarily indicate that the obstacle is fixed in the larynx. In 
the case just narrated, although the fruit-stone was impacted in the left 



FOREIGN BODIES IN THE AIE-TUBES— SYMPTOMS. 531 

bronchus and the larynx was free, the voice was hoarse and almost sup- 
pressed. 

If the substance lodge in the trachea below the larynx, the suffering 
produced is not very great, as a rule, so long as the passage remains 
pervious. In the often-quoted case related by Mr. McNamara of Dublin, 
in winch a boy who had constructed a whistle out of a plum-stone, inad- 
vertently drew the toy by a strong inspiration through the glottis, the 
object remained fixed transversely in the lower part of the larynx, and 
gave rise to a whistling sound as the air passed through it in expiration. 
The only inconvenience produced by the accident while the obstacle re- 
mained in this situation was an occasional suffocative cough ; but this did 
not prevent the boy from running about and playing as usual. 

In the bronchus the symptoms produced by the presence of a foreign 
body vary according as this is fixed or is free to move. If a smooth sub- 
stance, such as a fruit-stone, become fixed in the bronchus, it causes great 
distress by plugging the air-tube and arresting the function of the corre- 
sponding lung. The air cannot enter or escape. Consequently the patient 
experiences great dyspnoea from sudden loss of half his breathing surface. 
He has attacks of spasmodic cough from the irritation induced at the seat 
of obstruction, and on the affected side the vesicular murmur is weakened 
or suppressed. Catarrhal pneumonia in this case follows very quickly. 
If the impacted body be irregular in shape, so as still to allow the passage 
of air through the tube, there is less oppression of breathing, and in many 
cases less irritation in the lung ; also, the pathological results are more 
chronic in their course. 

If the intruding substance be free to move, as is sometimes the case 
with a rounded body which does not so readily become impacted in the 
air-tube, very curious consequences follow. When the object is carried 
against or into the larynx, it produces spasmodic cough and an agonizing 
feeling of suffocation. As it descends again into the lower tube there 
succeeds a period of comparative calm ; and the physical signs which have 
been described as indicating impaction of the substance in the bronchus 
may perhaps be noticed. This alternation of suffocative cough with 
intervals of more or less complete repose are very characteristic. It is in 
these cases that the presence of the foreign body can sometimes be detected 
by the ear and the touch. In the case of a little girl, aged two years, who 
was under my care in the East London Children's Hospital suffering from 
the presence of a haricot bean in the air-tubes, the physical signs noted 
by the House Surgeon, Mr. Scott Battams, on the evening of the day on 
which the accident happened were : ' ' Air enters fairly well into both 
sides of the chest. At the apices expiration is prolonged and wheezing. 
On listening at the middle of the right back a sound is heard as if a solid 
body were drawn down in inspiration and carried away again in a forced 
expiration." The child, although not much troubled by dyspnoea, suffered 
greatly from cough ; and when this was violent the finger and thumb 
placed on either side of the upper part of the trachea could feel a distinct 
impact as of some solid body striking this part of the tube with each im- 
pulse of cough. Afterwards with the stethoscope placed upon the same 
part a dull thud-like sound was distinctly audible as the object was forced 
upwards by the current of air. 

Diagnosis. — Whenever a foreign body has passed into the windpipe it 
is of the utmost importance to the patient that there should be no mystery 
as to the cause of his symptoms, for recovery will probably depend upon 
ready measures being taken for the expulsion of the offending substance. 



532 DISEASE IN CHILDREN. 

The diagnosis rests upon the history of the accident and the sudden occur- 
rence of the symptoms in a child previously healthy ; also, upon the nature 
and situation of the physical signs to be discovered on examination of the 
chest. 

The history is not always to be obtained. Thus, in the case of a baby, 
unless the child have been seen to play with some small object immediately 
before the suffocative attack occurred, the likelihood of a foreign body hav- 
ing passed into the trachea may not even be entertained. Again, the his- 
tory may be misleading. Attacks of spasmodic laryngitis may occur in a 
young child while at play ; and if any small objects likely to produce such 
symptoms are found within his reach, the inference that a similar object 
has been introduced into the air-passage is sufficiently obvious. If the 
attack of laryngitis occurred first under such circumstances, this inference 
would be almost unavoidable. Still, although not necessarily conclusive, 
a history of the probable introduction of a solid substance into the wind- 
pipe is of great value. If a child while in his usual health has been eating 
stoned fruit, or playing with small articles such as peas, haricot beans, or 
grains of corn, and is seized all at once with violent oppression of breath- 
ing and spasmodic cough, we should consider very carefully the evidence 
to be obtained from a physical examination of the chest. It must be re- 
membered that the first distress is only temporary, and is succeeded by a 
period of calm, of variable duration. When called to such a case, there- 
fore, we must not conclude because the child's suffering has subsided that 
all danger is at an end. 

The physical signs in these cases may be indicative of pulmonary irrita- 
tion or of more or less complete obstruction of a bronchus. The irritation 
set up in the air-tube leads quickly to increased secretion, so that more or 
less sibilant or sonorous rhonchus and bubbling rales are usually heard 
with the stethoscope. If in a case where the symptoms occurred suddenly 
under circumstances suggesting the introduction of a solid substance into 
the windpipe, the above signs of irritation are discovered on one side only, 
and that side the right side, the evidence must be looked upon as impor- 
tant. 

Signs of plugging of a bronchus are, however, of the greater value. 
Complete absence of breath-sound and of respiratory movement over the 
whole of the affected side without alteration in the normal resonance — these 
signs occurring suddenly in a child in whom suffocative cough began all at 
once in the midst of perfect health, would be strong evidence of the pres- 
ence of a foreign body in the air-tubes, even in the absence of any history 
pointing to such an accident. If in such a case violent suffocative cough 
breaks out again, and at the same time the morbid phenomena disappear 
from the chest, the vesicular murmur returning with natural loudness on 
the side previously silent, the phenomenon is very characteristic. These 
alternations of comparative calm and absence of breath-sound with violent 
spasmodic cough and perfectly normal physical signs may be looked upon 
as pathognomonic. If the impact of the imprisoned body can be felt and 
heard in the trachea during the cough, the evidence thus furnished of the 
presence of a solid substance in the air-passages is practically conclusive. 

If the tube, instead of being perfectly closed is partially permeable, ap- 
preciable weakness of the vesicular murmur may be noticed on the affected 
side. Such a sign occurring alone may have little importance attached to 
it ; but if with weak breathing over the right lung we notice sonoro-sibi- 
lant rhonchus or bubbling r ales over the upper part of the same side, the 
other lung being healthy, the combination is of some value. 



FOREIGN BODIES IN THE AIR-TUBES — TREATMENT. 533 

When the foreign body remains in the larynx caught in one of the ven- 
tricles, the resulting symptoms — aphonia, dyspnoea, violent croupy cough, 
and sense of choking — may suggest stridulous laryngitis or membranous 
croup. In such a case the history of the seizure, especially the sudden oc- 
currence of the distress in a child previously in a state of perfect health, 
is of great importance. In stridulous laryngitis, although the complaint 
often begins with much violence and quite suddenly, the spasm almost in- 
variably occurs at night, the child starting from his sleep with urgent 
dyspnoea ; and the symptoms subside completely after a short time. In 
the case of a solid substance in the larynx the access occurs while the child 
is awake and at play ; the dyspnoea is more continuous ; and the remission, 
if it occur while the foreign body remains in the neighbourhood of the 
larynx, is far less complete. 

In membranous croup the attacks of dyspnoea come on gradually, and 
slowly increase in severity ; the voice is not whispering at the first ; and in 
many cases patches of false membrane may be seen in the fauces. 

Prognosis. — If expulsion of the imprisoned body cannot be effected, 
the prognosis is very gloomy ; for although cases have been recorded in 
which the patient has continued for years to suffer little from the pres- 
ence of the solid substance in his air-passages, such cases are very excep- 
tional. Most commonly ill effects are not slow in making themselves evi- 
dent. The prognosis is more favourable if the impacted object is of irreg- 
ular shape, so as to allow air to pass and repass it in the tube. In such 
cases the patient may escape rapid death. In almost all the instances in 
which chronic phthisical changes have been developed as a consequence of 
the accident the substance has been of an irregular shape. 

If expulsion is effected, the prognosis necessarily depends upon the 
changes which have been set up by the irritation of the substance during 
its retention. Chronic phthisical symptoms often subside in a surprising 
manner after the ejection of the offending body, and in such cases, unless 
disorganization have proceeded too far, recovery may be hoped for. If ab- 
scess or gangrene have been set up in the lung, death generally ensues. 

Treatment. — When we are satisfied that a foreign body is retained in 
the air- tubes treatment must be energetic. Emetics have been found of 
little value and may therefore be dispensed with ; but if we are certain 
that the solid substance is of small size, the child should be at once turned 
head downwards and shaken in the hope of dislodging the imprisoned body 
and aiding its escape from the tubes. Often violent cough comes on during 
the operation, and sometimes so much spasm is excited in the glottis by 
the solid body pressing against it, that our efforts have to be promptly 
discontinued. This proceeding is more likely to be attended by good re- 
sults if the substance is small. A shot, a seed, or object of similar size, 
would be able to pass without difficulty between the vocal cords, while a 
larger one might become impacted in the glottis and cause speedy death 
by suffocation. Whenever, therefore, the foreign bod}' is known to be of 
some size, it is wiser to postpone all violent measures, such as eversion and 
succussion, until an artificial opening has been established in the trachea. 
This procedure is equally important whether the imprisoned body be fixed 
or be free to move. If it be fixed, the air-tube can be directly searched by 
a long forceps, and the object may sometimes be seized and withdrawn in 
this manner. If it be free to move, an artificial opening in the trachea is a 
great aid to its escape, as under these altered conditions the glottis relaxes 
readily and there is no risk of dangerous spasm. 

After the operation the imprisoned body may be ejected through the 



534 DISEASE IN CHILDREN. 

wound or may pass through the relaxed glottis. In the latter case it is apt 
to be swallowed. If, therefore, it be not found after the signs of suffering 
have subsided, the stools must be carefully examined. 

If the early measures for promoting the escape of the solid body do not 
succeed, or if on account of the size of the substance we fear to employ them, 
it is seldom judicious to delay the operation of tracheotomy. It must be 
remembered that it is only in exceptional cases that the continued presence 
of a foreign substance in the air- tubes has been borne without dangerous 
injury to the lung. As long as it remains in the respiratory passages there 
is constant danger of suffocation from the lodging of the object in the 
larynx, and of serious disorganization of the lungs from the irritation set 
up in the tubes. Therefore, if we are satisfied that a solid body is impris- 
oned in the passages, the fact that the resulting symptoms are not urgent 
should not induce us to postpone the operation. As Mr. Barwell has ob- 
served, "If a body be impacted in the larynx or trachea, urgent symptoms 
will mean merely increased irritability and spasm of the glottis, and on re- 
moval of the foreign body this will naturally cease. If the body be in the 
bronchus and do not move, urgent symptoms will mean the establishment 
of serious disease in the lung," and this may not disappear when the for- 
eign substance is removed. 

The operation is equally necessary whatever be the nature of the 
substance in the trachea. Soft matters, such as gristle, etc., will not be- 
come disintegrated in the air-tubes ; and small vegetable substances, such 
as seeds and grains of corn, may swell up to a much larger size through 
absorption of moisture. 



Part 7. 
DISEASES OF THE HEART. 



CHAPTER I. 

CONGENITAL HEART DISEASE. 



Like other parts of the body the heart is subject to malformations from 
arrest of development. These vary in importance according to the period 
of intra-uterine life in which they occur ; but all, since they affect the 
centre of the circulatory system, materially hamper the distribution of 
the blood-current and therefore interfere with the due discharge of all the 
nutritive functions of the body. 

In its progress from the simplicity of its rudimentary state to the com- 
plex machinery of the fully developed organ, the heart passes through a 
variety of changes. At first a mere tube doubled upon itself, it soon be- 
comes divided into three cavities —a simple auricle, a simple ventricle, and 
the arterial bulb. At this stage the organ resembles a horse-shoe in 
shape, the ventricle occupying the position of the curve. This cavity then 
begins to bulge out more conspicuously at its lower part so as to suggest 
by its appearance the later form of the heart ; and at the same time the 
auricle and the bulb approach more closely together. Next, the auricle 
and ventricle become each divided into two parts by a septum ; and the 
bulbus arteriosus is also divided into two channels which are the future 
aorta and pulmonary artery. The auricular and ventricular septa are 
each at first incomplete, so that the cavities severally communicate ; and 
the opening in the auricular septum — the foramen ovale — remains open 
until birth. 

Just before the completion of intra-uterine existence the course of the 
blood-current is as follows : — Starting from the placenta, in which it has 
been to a certain extent purified and recharged with oxygen, the blood 
enters the body of the foetus through the umbilical vein and is conveyed 
to the under service of the liver. At this point a portion passes directly 
into the inferior vena cava by the ductus venosus; the remainder joins the 
blood in the portal vein and circulates through the liver before it reaches 
the inferior vena cava and is conveyed with the first portion to the right 
auricle. Here it meets with the blood returning from the head and neck 
by the superior vena cava. The two currents do not, however, mix. That 



536 DISEASE IN CHILDREN. 

coming from the head passes, as it would do in the adult, through the 
auriculo-ventricular orifice to the right ventricle. From this point a small 
quantity reaches the lungs through the pulmonary artery ; but the larger 
portion is directed through the ductus arteriosus into the aorta below the 
origin of the great vessels, and passes to the lower part of the body and 
the placenta. The blood reaching the right auricle by the inferior vena 
cava, instead of entering the right ventricle, is directed by the Eustachian 
valve through the foramen ovale into the left auricle. Consequently, 
this portion of the blood also escapes the passage through the lungs, and 
is distributed by the left ventricle to the head and body generally through 
the aorta. 

At birth, the lungs, which had been previously inactive, come into play, 
and blood is drawn into them through the pulmonary artery. As a 
necessary consequence, the foramen ovale l and ductus arteriosus — the 
channels by means of which the passage through the lungs had been 
avoided, become useless. The arterial duct contracts and ceases to be 
pervious ; while the foramen ovale also closes and the separation of the 
auricles is henceforth complete. 

The arrest of development of the heart, which is the cause of the con- 
genital malformation, may occur at any of the stages which have been 
referred to. The heart may retain its nearly primitive form of a double 
cavity with only rudimentary divisions between the two sides, and the 
aorta and pulmonary artery may be still undeveloped from the original 
arterial trunk. This form is not common, but examples have been no- 
ticed. In the earliest of these, placed on record by Mr. Wilson in 1788, 
the infant survived its birth seven days. 

If the arrest take place at a later period, the septa dividing the cavities 
are more nearly complete, and the aorta and pulmonary artery are distinct 
vessels. This condition is far more common than the preceding. Its 
prominent feature, in addition to the still imperfect state of the partitions, 
is a displacement or even a transposition of the great vessels. The aorta 
is displaced to the right, arising in part from the right ventricle ; or it 
springs completely from that cavity and the pulmonary artery takes its 
origin from the left ventricle. When the aorta is merely displaced to the 
right, without malposition of the pulmonary artery, we usually find some 
obstruction to the passage of blood from the right ventricle through the lat- 
ter vessel. The artery is too small, or its valves are incomplete, or the 
blood is prevented from passing freely into it by some constriction of the 
ventricle near the outlet, or its channel may be even entirely obliterated. 
In all such cases the foramen ovale must remain open or the circulation 
could no longer be carried on. The blood being unable to find its way in 
sufficient quantity to the left side of the heart through the lungs, con- 
tinues to follow its original course through the opening in the auricular 
septum, and the foramen ovale is prevented from closing. If, however, in 
such a case the aorta arise sufficiently to the right to allow of the escape 
of blood through it from the right ventricle, the foramen ovale and ductus 
arteriosus may cease to be pervious. 

Constriction of the pulmonary artery with deficiency in the septum of 
the ventricles, so that the aorta communicates with the right ventricular 
cavity, is the commonest form of congenital malformation of the heart. 
Whether in such a case the foramen ovale and ductus arteriosus are closed 

1 Under normal conditions the foramen ovale should be closed by the end of the 
first week, and the ductus arteriosus by the end of the third month after birth. 



CONGENITAL HEART DISEASE— MORBID ANATOMY. 537 

or not depends, as has been said, upon the freedom with which the blood 
can escape from the right side of the heart through the displaced aorta. 
If the right ventricle is not unduly distended, and the pulmonary artery 
allows enough blood to get away, both these channels may become closed. 
In the other case, where the aorta and pulmonary artery are transposed, 
the septum of the ventricles is usually imperfect, and the foramen ovale 
and ductus arteriosus still remain open. 

Sometimes the descending aorta is found to arise from the pulmonary 
artery, being apparently a continuation of the ductus arteriosus. In this 
case a small ascending aorta springs from the left ventricle to supply the 
head and neck by the usual vessels. The pulmonary artery communicates 
through an opening in the ventricular septum with the left ventricle. The 
foramen ovale is usually closed. 

In contradistinction to the class of cases where the foetal openings re- 
main pervious after birth is another class in which these orifices close too 
early, before uterine life has reached its term. If the foramen ovale is 
obliterated prematurely, the whole quantity of blood has to pass through 
the pulmonary artery and ductus arteriosus. Consequently, the right side 
of the heart is enormously hypertrophied while the left side is smaller 
than natural. In cases where the ductus arteriosus has undergone early 
obliteration, the aorta usually springs from the right ventricle, and this 
vessel commonly gives branches to the lungs, the pulmonary artery being 
very small and rudimentary. 

Besides the varieties which have been mentioned, the congenital disease 
may also consist in defects in the valves, or in narrowing of the orifices of 
the large vessels which spring from the heart. Sometimes, as in the pre- 
ceding cases, the defect may arise from malformation, as when the num- 
ber of the valves is deficient or otherwise abnormal ; but it may also be 
due to intra-uterine endocarditis. Inflammation, when it attacks the foetal 
heart, almost invariably affects the right side, which at this period of life 
is more active than the left. The tricuspid valve may be beaded, or the 
pulmonary semi-lunar valves may be more or less adherent. In many 
cases the three pulmonary valves are found united into a funnel-shaped 
dome with a small orifice at the apex, through which the blood is pro- 
pelled with difficulty. A similar atresia of the aortic orifice is much less 
frequently met with. When the latter malformation exists, the arteries of 
the head and upper limbs are probably filled through the pulmonary artery 
by the ductus arteriosus. 

It is possible that these inflammatory lesions ma}^ be occasionally ex- 
cited, as Dr. Von Hoffman suggests, by extravasation into the placenta, 
from which hsemorrhagic foci, pathological products, may be introduced 
through villous absorption into the foetal circulation. 

Morbid Anatomy. — In addition to the malformations which have been 
described, the heart is always found to be greatly enlarged, especially on 
the right side. Moreover, morbid conditions are usually seen in other 
organs. There is often more or less atelectasis of the lungs, and the ex- 
panded portions have a dark, congested appearance. The liver and spleen 
are not unfrequently swollen and congested ; and effusions may be found 
in the pleura and peritoneum. Also, morbid conditions of the brain are 
common. There may be congestion or inflammation or effusion ; or an 
abscess may be formed in its substance. 

The congenital imperfections of the heart may be complicated by in- 
flammation in or around the organ, for the original malformation, far 
from guarding the patient from subsequent inflammation, appears rather 



538 DISEASE m CHILDEEN. 

to prepare the way for it. "We may therefore find the anatomical charac- 
ters of endocarditis or inflammation of the pericardium. 

Symptoms. — In cases of congenital heart disease the most striking 
symptom is the purplish or livid tint of the skin which, if the child sur- 
vive its birth many months, rarely fails to be developed. Indeed, from 
this peculiarity of colour such cases are often spoken of as cases of cyano- 
sis or " morbus coeruleus." The depth of the purple tint varies greatly in 
different subjects. In some it merely gives a dusky or swarthy hue to the 
skin. In others the discolouration may reach a deep purple or even almost 
a black colour. It is distinguishable in all parts of the body ; but is most 
noticeable in the cheeks, lips, and eyelids, and also in the ends of the 
fingers and toes. Even in the same subject the symptom is liable to 
variation. While the child is completely at rest the tint most nearly ap- 
proaches the normal colouring ; but movement, especially fretfulness or 
anger, makes the skin darker at once. The cause of the cyanotic tint has 
been the subject of discussion. By Morgagni it was attributed to intense 
general congestion, and by Hunter to great contamination of the arterial 
current with unoxygenized blood. The latter view has been shown to be 
untenable. Cyanosis may exist without any admixture of venous and arte- 
rial blood ; and in many cases where such admixture occurs the depth of 
tint is not in proportion to the amount of venous blood which is poured 
into the aorta. Dr. Peacock gives his support to the theory of Morgagni, 
and attributes the discolouration to stasis of blood in capillaries dilated by 
long-standing congestion, aided by imperfect aeration of the whole mass 
of the circulating fluid. 

The cyanotic tint is not always an early symptom. We often find that 
the child at birth presented no peculiarity of colour, and that it was only 
after an interval of weeks or months that anything was noticed to excite 
suspicions of disease. In less common cases the tint of the skin is normal 
throughout. 

In addition to the blueness of the ends of the fingers and toes, these 
parts are usually clubbed from systemic venous congestion, and the nails 
are incurvated. The shape of the chest is often peculiar. It is sometimes 
called " pigeon-breasted," but the prominence of the sternum is only no- 
ticeable at the lower part from flattening in each infra-mammary region. 
At the upper part the chest is abnormally prominent and rounded. The 
coldness of the hands and feet is another striking peculiarity in a cyanotic 
child. Indeed, the external temperature of the body may* be several de- 
grees below the normal level ; but if the thermometer be placed in the rec- 
tum the internal temperature will be found little lower than natural. It 
is, however, subject to variations, being sometimes for several days below 
the normal level (97°-98°) ; at other times more nearly natural. In these 
patients, as in healthy children, the ordinary heat of the body is liable to 
be disturbed by teething and other sources of irritation ; and is sometimes 
found to run up to 102° or even higher from this cause. 

Dyspnoea and palpitation of the heart are common symptoms. In the 
case of an infant the mother often remarks upon the beating of her child's 
heart when the patient is washed or otherwise disturbed ; and older chil- 
dren may complain spontaneously of the throbbing when they attempt to 
run. At these times there is usually shortness of breath, and cough may 
be present. In some cases when the cyanosis is extreme, the cough may 
be accompanied by the expectoration of blood. The pulse is often irreg- 
ular and intermittent, but its strength is fair. 

Sometimes dropsical symptoms come on. There may be cedema of 



CONGENITAL HEART DISEASE — SYMPTOMS. 539 

the legs, or ascites ; but serous effusions are less common than might be 
supposed, for, as Dr. Chevers has pointed out, the venous system seems to 
adapt itself to the overloading. The right auricle, cava, and systemic veins 
are often of unusual capacity from the first ; and the veins of the liver are 
capable of containing a vast quantity of delayed blood. The superficial 
veins of the chest or limbs are rarely more visible than natural, but the 
skin is habitually dry and may be harsh. The liver and spleen can often 
be felt to be enlarged ; and on account of the congestion of the kidneys 
the urine is habitually scanty and high coloured. On account, too, of the 
congestion of the alimentary canal, the tongue is generally foul, the breath 
offensive, and the digestion feeble. The appetite is poor or capricious ; 
and the bowels costive or irregular, with clay-coloured pasty stools. The 
gums are often dark-coloured and spongy-looking, and may be ulcerated 
at their edges. Sometimes they bleed. 

Cyanotic children are generally irritable and easily disturbed. Conse- 
quently at a first examination it is often impossible to come to a satisfac- 
tory conclusion even as to the physical signs present in the case. These 
are liable to vary according to the character of the congenital lesion, and 
may possibly be absent altogether ; for if the malformation consist in a 
mere transposition of the aorta and pulmonary artery, without narrowing 
of the channels or persistence of the foetal openings, no murmur will be 
heard, and careful examination will detect no sign of cardiac enlargement. 
The most common malformation, as has been said, is that in which the 
pulmonary artery is greatly constricted, and the septum between the ven- 
tricles is deficient, so that the aorta appears to arise in part from the right 
ventricle. In such a case there is great hypertrophy of the right ventricle ; 
we find a very strong pulsation all over the precordial region, and a 
forcible impulse between the left nipple and the ensiform cartilage. The 
impact may be accompanied by a systolic thrill. On listening to the 
chest we hear a loud systolic murmur in the course of the pulmonary 
artery. In the case of a boy who died at the age of nearly six years in the 
East London Children's Hospital with this condition, the apex beat of the 
heart was in the fifth interspace in the nipple line. The impulse was felt 
very strongly over the whole prsecordial region, in the epigastrium, and 
even to the right of the lower part of the sternum. The arteries in the neck 
also pulsated strongly. A loud systolic murmur was heard all over the front 
and back of the thorax. It was rather louder at the base of the heart than 
at the apex, and became much fainter towards the armpits. The point 
of greatest intensity was over the site of the pulmonary valves. In this 
child there was no discolouration of the skin. 

Even a patent foramen ovale without constriction of orifices or other 
abnormal condition will give rise to a murmur. In a case published by 
Dr. Baltnazar Foster — in a little girl of two years old — a faint murmur 
was heard with the latter part of the first sound at the level of the lower 
edge of the third rib at its junction with the sternum. It did not, however, 
extend over a wide area, and was audible neither at the base of the heart 
nor the apex. 

Infants who suffer from congenital malformation of the heart are 
usually thin. If, however, the patient survive the period of infancy, he 
may not be wasted and may even have a sturdy appearance. He is 
usually lethargic and dull of intellect ; and is cautious in his movements, 
as experience has taught him that exertion is apt to be followed by palpi- 
tation and dyspnoea. In most cases where serious malformation of the 
heart exists the patient is subject to attacks of syncope, and often symp- 



540 DISEASE IN CHILDEEN". 

toms occur referable to disorder of the nervous system. In the case re- 
ferred to above, the patient died of cerebritis. Another cyanotic child 
under my care in the East London Children's Hospital— a little girl nearly 
two years old — suffered, while she remained under observation, from general 
loss of power, with ptosis of the right eyelid and contraction with rigidity 
of the muscles of the left forearm. The child had all the signs of carious 
disease of the right petrous bone. Disease of this part of the skull seems 
to be a not uncommon lesion in children who suffer from congenital mal- 
formation of the heart. Dr. Lawrence Humphry has kindly communicated 
to me the notes of a case which occurred during his period of office as 
Kesident Physician in the Victoria Park Hospital. The j)atient — a cyanotic 
boy between five and six years old — had suffered from long-continued 
otorrhcea. A fortnight before his death the discharge ceased. The child 
then began to complain of headache, which became very severe. This 
symptom was soon followed by attacks of violent convulsions, without loss 
of consciousness in the intervals, and the boy died in a few days. After 
death, in addition to the ordinary form of congenital malformation (stenosis 
of the pulmonary artery, deficiency in the ventricular septum, and origin of 
the aorta from both ventricles) an abscess was found in the middle lobe 
of the left cerebral hemisphere, and the petrous bone on that side was dis- 
eased. 

Convulsions are very common, especially in infants ; and startings and 
twitchings during sleep are seldom absent whatever be the age of the pa- 
tient. Another curious symptom is great heaviness and somnolence. In 
many cyanotic children attacks of uncontrollable sleepiness form a promi- 
nent feature in the case. These attacks are apt to come on after a meal. The 
child shows symptoms of great drowsiness ; the face becomes purple, and 
the breathing slow and heavy. In extreme cases the sleep becomes so 
profound that it resembles coma and the child cannot be roused. After 
some hour's, however, the patient revives, his heaviness passes off, and he 
is restored to his normal condition. 

The duration of life is very variable. It is dependent chiefly upon the 
degree of obstruction to the circulation. Nearly one-half of the cases die 
before they have completed the first year, and two-thirds before they are 
two years old. Death often occurs in a convulsive fit ; and infants usually 
die in or directly after such a seizure. Moreover, attacks of syncope are 
common, and the failure of the heart's action is sometimes not recovered 
from. In some cases the patient falls a victim to pneumonia or other in- 
tercurrent disease ; indeed, on account of the impaired state of nutrition 
usually prevailing, the resisting power of the child is feeble, and derange- 
ments prove fatal which a stronger subject would have little difficulty in 
overcoming. Many of these children become tubercular or phthisical, and, 
as has been said, in not a few cases death is preceded by symptoms point- 
ing to cerebral mischief. 

Diagnosis. — A child, cyanotic from malformation of the heart, presents 
a very characteristic appearance. His dusky tint, his purple lips and eye- 
lids, his livid and clubbed finger-tips — these symptoms, together with the 
physical signs and the history of the patient, can leave little doubt as to the 
existence of a congenital lesion of the heart. If, however, cyanosis is ab- 
sent, the nature of the case is less immediately recognisable ; but by a care- 
ful review of the physical signs we can usually arrive at a correct conclu- 
sion. If we are able to localize the murmur at the pulmonary orifice, and 
can discover signs of hypertrophy of the right ventricle (increase Of the 
heart's dulness to the right with pulsation in the epigastrium), these signs 



CONGENITAL HEAET DISEASE— DIAGNOSIS. 541 

are almost pathognomonic of congenital disease, ior endocarditis affecting 
the right side of the heart is rare after birth. Sometimes, on account of 
the small size of the chest in young subjects, it is impossible, especially in 
an infant, to discover the point of greatest intensity of the murmur. In 
such a case, signs of hypertrophy of the right heart are doubly important ; 
and if we notice clubbing of the finger-ends, and find that after movement 
the child's face becomes livid or his lips blue, the existence of congenital 
heart disease, in the absence of any affection of the lungs, may be safely as- 
serted. According to some observers, attacks of dyspnoea alone, occurring 
from trifling causes, are very suspicious of this form of lesion. Louis was 
of opinion that " suffocative attacks brought on by the slightest cause, 
often periodic, always very frequent, and accompanied or followed by syn- 
cope, and with or without blue discolouration of the body, generally " formed 
sufficient grounds for the diagnosis of an abnormal communication between 
the right and left cavities of the heart. Again, the occurrence of tubercu- 
losis in a child the subject of old-standing heart disease, although not con- 
clusive evidence, points very decidedly to a congenital origin for the car- 
diac mischief. 

Even in cases where all necessary symptoms are present, and the con- 
genital origin of the heart-lesion is unmistakable, the exact variety of mal- 
formation must often remain a mystery. The difficulties in ascertaining the 
form in which the arrest of development has occurred are very great. In 
the case of a fully developed heart we are dealing with an organ the 
structure of which is known. We are acquainted with the number and 
situation of its openings, the number and mechanism of the valves which 
close them, and the direction normally taken by the current of blood. In 
such a" heart any morbid alteration of the physical signs has a definite 
meaning ; and in ordinary cases there is little uncertainty as to the cause 
which has given rise to it. In the case of a heart the -seat of a congenital 
malformation, the conditions are very different. The number of openings 
is undetermined ; their position is doubtful, and even the direction in 
which the blood is flowing can only be conjectured. In such cases, there- 
fore, an exact diagnosis is often impossible. Still, there are certain general 
rules which should not be forgotten. Thus, some forms of malformation 
prove very quickly fatal. An infant whose heart remains in a primitive 
state, consisting merely of two cavities, will probably be dead within a 
month. Therefore at a more advanced age this variety may be excluded. 
Another form of congenital disease which usually has an early termination 
is transposition of the aorta and pulmonary artery. Children in whom 
this form of malformation occurs rarely live longer than two or at the most 
three years. One little boy under my care with this form of lesion sur- 
vived to the age of eighteen months ; but the majority of the recorded 
examples have died within the first twelve months. So, also, the variety 
which consists in the origin of the aorta from the pulmonary artery is not 
likely to be present in a child who has survived the first year. 

In children who have reached the age of three years the above condi- 
tions may be excluded with a high degree of probability. At this age we 
should search for signs indicative of atresia of the pulmonary artery. If 
we can localize the murmur over the pulmonary valves, and can ascertain 
the existence of hypertrophy of the right side of the heart, we may safely 
infer the presence of contraction of the orifice of the pulmonary artery. 
In such a case there is probably also deficiency of the ventricular septum, 
I with a communication between the aorta and the right ventricle, and per- 
haps patency of the arterial duct. This, it may be repeated, is the 



542 DISEASE IN CHILDREN. 

commonest form of congenital malformation. Still, other morbid condi- 
tions of which we know nothing may also be present. Patency of the 
foramen ovale is seldom the only abnormality, but, if in a child of three 
years old or upwards we find the symptoms of congenital heart disease 
without cardiac murmur, or with a very faint bruit limited strictly to the 
level of the third interspace towards the middle line, and without signs of 
hypertrophy of the right ventricle, this condition may be suspected. In 
no case, probably, can a positive diagnosis be arrived at ; at least, we can 
never say that the condition diagnosticated is the only cardiac lesion 
present. 

Prognosis. — The prospects of a child, the subject of congenital mal- 
formation of the heart, are necessarily very unfavourable. On account of 
the difficulties under which his circulation is carried on, and the persistent 
congestion of his whole venous system, the child's nutrition is faulty and 
his vitality low. He has therefore little power to throw oft* even trifling 
derangements, and is peculiarly sensitive to disturbing influences. In ad- 
dition, then, to the dangers directly attendant upon his congenital defect, 
he is exposed to constant risk from the serious consequences, in his en- 
feebled state, of the ordinary ailments of childhood. Every change in the 
growth and development of the infant is a new period of trial. The first 
establishment of the respiratory function at birth, the occurrence of denti- 
tion, the time of weaning, and all the innumerable causes of disturbance 
to which infant life is liable, are distinct sources of peril. To one or 
another of such dangers a large proportion of these patients succumb ; 
and, as has already been stated, hardly one-third of the whole number of 
cases survives to the age of two years. 

On account of the difficulty of ascertaining the exact variety and extent 
of the cardiac defect, the prognosis during the first few months of life is 
especially serious. .Later, as the child grows and arrives at a period when 
the more fatal forms of malformation may be excluded, his prospects im- 
prove ; but they can rarely be said to be otherwise than unfavourable, for 
a comparatively small proportion of these patients live to attain adult years. 

Of special symptoms, some should be regarded with anxiety. Frequent 
attacks of syncope are dangerous ; great drowsiness is of unfavourable 
omen ; and convulsions or other sign of cerebral irritation have a very sin- 
ister meaning. According to Dr. Chevers, failure of the renal secretion, or 
the occurrence of albuminuria, as indicating the probable beginning of 
structural changes in organs which have always been hampered in the dis- 
charge of their functions, is to be viewed with much apprehension. 

Treatment. — The treatment of these cases consists in the adoption of wise 
rules for the diet and general management of the patient, and in early atten- 
tion to any intercurrent disorder by which he may be attacked. On account 
of the general sensitiveness to chills, and the tendency to lowering of the 
temperature, the child must be warmly dressed with a flannel band to his 
belly, and should be clothed in some woollen material from head to foot. 
His diet should be carefully arranged so as to avoid excess of fermentable 
matters, such as starches and sweets ; and he should be taken out of doors, 
whenever the weather is not too unfavourable, in his nurse's arms or a 
suitable carriage. If a perambulator be used, a hot bottle to the child's 
feet is a necessity unless the weather be warm. The patient's bowels should 
be kept regular, and an occasional mercurial purge is useful to afford some 
relief to his congested liver. If palpitations are violent, small closes of the 
infusion of digitalis may be given ; and Dr. Peacock speaks highly of the 
beneficial effects of Dover's powder. It is important to excite the regular 



CONGENITAL HEAET DISEASE — TREATMENT. 543 

action of the skin, which in these patients is habitually dry. Tepid baths 
should be given twice a day, and should be always followed by careful 
frictions over the whole body with the hand. Small quantities of alcohol 
are also of service, and may be given in the form of brandy or the St. 
Kaphael tannin wine. The attacks of dyspnoea are best treated by stimu- 
lants and small doses of digitalis and ammonia. 

Any catarrh, whether of the lungs or bowels, must be attended to with- 
out delay ; and if albuminuria be detected in the urine, or the renal secre- 
tion become scanty, gentle aperients and diuretics should be at once re- 
sorted to. In cases of extreme discolouration, the peroxide of hydrogen 
has been recommended ; and Dr. Balthazar Foster states that given three 
times a day in eight-minim doses the beneficial effects of the remedy are 
very decided 



CHAPTER IT. 

CHRONIC VALVULAR DISEASE OF THE HEART. 1 

Chronic disease of the heart is very common in childhood ; and there are 
few forms of valvular lesion found in the adult which may not be also met 
with in the young subject. The signs and symptoms to which such faulty 
conditions give rise are much the same at all ages. A child, like an adult, 
may have valvular disease without himself being conscious of discomfort or 
betraying to others any sign of inconvenience ; or he may suffer from 
breathlessness, palpitation, general cedema, and all the other symptoms 
which are liable to arise in an older person similarly affected. The physi- 
cal signs of valvular lesion, and of consequent alteration in size of the organ, 
also resemble very closely those met with in adult life. It is not, therefore, 
necessary to enter into these subjects at great length. It will be sufficient 
to point out any peculiarities of feature conferred upon the cardiac disease 
in the child by the youthful age of the patient. 

Causation. — Amongst the causes of valvular defect of the heart, rheuma- 
tism takes by far the most important place. To this disease, indeed, most 
of the cases of heart disease occurring in early life are to be attributed. 
The manifestations of rheumatism in the child, as is stated elsewhere, are 
often very trifling ; and in infancy, on account of the difficulty of referring 
signs of distress to their true source, the disease no doubt often escapes 
detection altogether. Next to rheumatism, scarlatina is perhaps the most 
common cause of endocardial inflammation. This disease is often followed 
by joint pains and other symptoms indistinguishable from rheumatism ; and 
chronic valvular disease of the heart appears in not a few cases to owe its 
origin to this exanthem. According to Bouillaud, measles is also an occa- 
sional precursor of endocarditis ; and Dr. Samson has recorded a case in 
which both pericarditis and endocarditis occurred a fortnight after con- 
valescence from measles had begun. This fever, however, is no doubt a 
much less common cause of the valvular disease than the other maladies 
which have been mentioned. In certain cases, chorea appears to be a start- 
ing point for valvular mischief. Sometimes, without any evidence of rheu- 
matism, we find a murmur become developed in the course of the choreic 
attack ; and it may happen that the morbid sound continues after the ces- 
sation of the nervous derangement, and is accompanied after a time by 
displacement of the heart's apex and other signs of hypertrophy. Still, in 
these and other cases where no history of rheumatism is to be obtained, it 
is possible that the endocardial lesion ma5 T still have a rheumatic origin. 
The tendency of this disease is to attack the fibrous tissues of the body 
generally ; but all need not suffer at the same time. The selection, even, of 
the joints to be affected by the disease is apparently capricious. Some are 



1 Acute peri- and endo-carditis and their consequences are considered in the chapter 
on acute rheumatism. 



CHRONIC VALVULAR DISEASE OF THE HEART. 545 

attacked while others are passed over. It is surely, therefore, not unreason- 
able to suppose that the fibrous tissues of the heart may be implicated 
while those of the joints are left unharmed. In addition to the preceding, 
syphilis may be an occasional cause of the heart lesion, for valvular imper- 
fection is sometimes found in very young infants, the subjects of inherited 
syphilis. 

Atheromatous degenerations, which are so common a cause of valvular 
lesion in the adult, rarely occur in early life. It once, however, happened 
to me to meet with a small calcareous mass on one of the aortic valves in 
a little girl three years old. The mass had given rise during life to a 
systolic murmur which was most intense at the base of the heart, but 
could be heard distinctly at all parts of the chest. This child had never 
had rheumatism, as far as could be discovered, but had suffered from 
measles nearly two years previously. 

Rickets has been said to be a cause of hypertrophy of the heart ; but I 
cannot say that I have ever myself met with a case of cardiac enlargement 
which I was able to attribute to the chest distortion produced by this dis- 
ease. When the framework of the thorax is much deformed, the heart is, 
no doubt, forced more forwards towards the wall of the chest, and a larger 
area of impulse is consequently perceptible. It is common in such cases 
to be able to feel the contractions of the right ventricle in the epigastrium ; 
but this sign alone is insufficient proof of enlargement of the right side of 
the heart in the absence of extension of dulness to the right of the sternum, 
and other necessary signs of that condition. 

In some cases valvular lesions are probably congenital in their origin, 
arising from endocarditis occurring during intra-uterine life. In most of 
these cases the valves on the right side of the heart only are attacked. 
Chronic valvular disease, according to some authors, is more common in 
boys than in girls ; but my own experience would point to a directly op- 
posite conclusion. 

Morbid Anatomy. — In most cases of chronic valvular disease in the 
young subject the lesion consists in a beading or puckering of valves or 
other cause of insufficiency, or in a narrowing of the valvular opening. 
The valve most commonly affected is the mitral ; the next, that closing the 
aorta. Beading of the tricuspid valve is rarely seen. This lesion, how- 
ever, occurred in a case under my care in the East London Children's 
Hospital. A girl aged thirteen was admitted, suffering from general venous 
congestion, cyanosis, and anasarca. The child's ringers were clubbed, and 
her breathing was hurried with some degree of orthopncea. The patient 
was said never to have had rheumatism, but had suffered from measles and 
scarlatina, and seven years previously had had an attack of chorea, from 
which all her trouble was dated. On examination there was evidence of 
great hypertrophy of the left ventricle, and a strong pre-systolic thrill and 
loud pre-systolic murmur were discovered at the apex. There was also a 
short diastolic thrill at the base to the left of the sternum, and a diastolic 
murmur was heard at this spot. There were, in addition, signs of double 
hydrothorax. On examination of the body after death, the heart was 
found to be very large, especially transversely, and to weigh twelve and a 
half ounces. The right auricle and ventricle were much distended with 
dark post-mortem clot ; and were both dilated, the ventricle being much 
hypertrophied. The tricuspid valve seemed to be competent, and measured 
three and a half inches in circumference. Its edges on the auricular sur- 
face were fringed with papillae which measured about one-eighth of an inch 
in length. The left auricle was dilated and hypertrophied to a less degree 
35 



546 DISEASE IN CHILDREN. 

than the left ventricle. The mitral orifice was contracted to a mere slit, 
with a circumference of one inch. The pulmonary artery was very large, 
but the valves were competent. The aortic orifice leaked very slowly by 
the water test, but had probably been competent during life. The lungs 
and other organs showed the usual signs of prolonged venous congestion. 

The heart was shown at a meeting of the Pathological Society by my 
colleague, Dr. Badcliffe Crocker. In his comments upon the case, Dr. 
Crocker suggested that the basic systolic murmur had been probably due 
to a temporary incompetence of the pulmonary valves, owing to dilatation 
of the artery from extreme congestion of the lungs. Such a cause for 
pulmonary regurgitation is supported by the authority of Hope and Hayden. 
The tricuspid valve is seldom diseased primarily. When the seat of thick- 
ening or other lesion, it almost always seems to be affected secondarily, 
being usually found, as in the above case, in connection with a serious 
stricture of the mitral orifice. 

Adhesion of the layers of the pericardium is found in not a few cases. 
The adhesions are often very thick and strong ; and the lymph appears to 
have penetrated between the muscular fibres of the heart ; for these are 
often torn in the attempt to separate the firmly attached serous membrane. 
Great hypertrophy and dilatation of the organ usually accompanies this 
condition. 

It is important not to mistake for pathological beading of valves a 
condition to which Parrot has drawn attention. According to this ob- 
server, in a large proportion of infants who die during the first month 
after birth, hsematomata and fibrous nodules are found on the auriculo- 
ventricular valves. The hcematomata are little spherical or conical tumours 
of a dark purple or nearly black colour. In size they may be so small as 
scarcely to be visible to the unaided sight, or may reach the size of a 
millet-seed. They are placed singly or are arranged in groups. These 
little projections are seated exclusively on the mitral and tricuspid valves 
at the part where the tendinous cords are inserted. They lie close to the 
free edge of the valve, and are covered by the most superficial layer of the 
endocardium. In a short time they lose their colour, and sink down into 
little flattened prominences before they finally disappear. They cease to 
be visible shortly after the end of the first month of life. Parrot attributes 
their origin to rupture of intravalvular vessels. The fibrous nodules oc- 
cupy the same situation as the preceding, and are seen as little flattened 
projections widened towards the base. They are composed of a dense 
fibro-elastic tissue. These nodules, especially the former, occur too fre- 
quently, and are too harmless in their character, to be ranked as patholo- 
gical lesions, for no ill results appear to follow their presence on the valves. 
Strictly speaking, no doubt, they are not healthy productions, but they 
scarcely merit the name of disease. 

The effect upon the heart's substance of the morbid changes in the 
valves is much the same in the child as in the adult. Hypertrophy and 
dilatation follow, and in severe cases may reach an extreme degree. In 
the young subject there is great power of compensation ; and we often 
find that the vigour of the heart becomes rapidly increased so as to make 
up for the valvular deficiency, and the health of the child is seemingly un- 
impaired. In examining the heart in early life we must not make the 
mistake of attributing all murmurs to valvular imperfection — that is to 
say, to a degree of imperfection injurious to health. It is more common 
in the child than in the adult to find a systolic murmur at the apex of the 
heart, without any other sign of regurgitation through the auriculo-ven- 



CHEOXIC YALYELAE DISEASE OF THE HEAET. 547 

tricular opening. Such a murmur may persist for years, and finally disap- 
pear without having led to any alteration in the site of the apex beat, or 
other indication of ventricular hypertrophy. In such cases there is prob- 
ably some roughening of the surface of the valve, which, however, still re- 
mains perfectly competent to perform its functions. 

Symptoms. — A valvular lesion of the heart does not necessarily give 
rise to symptoms of discomfort ; and it seems that in some children years 
can pass without any sign of distress being manifested on account of the 
cardiac mischief. It is common to find signs of valvular insufficiency in a 
child who has been brought for advice on account of some casual derange- 
ment quite unconnected with the condition of the heart ; and even in 
cases where breathlessness has been noticed, it is often a recent symptom, 
while the enlargement of the organ indicates that the valvular lesion is of 
much more remote origin. When regurgitation is slight, the increase of 
power quickly acquired by the heart compensates completely for the de- 
fect, and no unfavourable symptoms are noticed until dilatation occurs, or 
a new attack of endocarditis aggravates the original imperfection. 

Usually, the earliest and by far the most commonly present symptom is 
breathlessness. It is noticed that when the child plays at any boisterous 
game, he becomes very pale, and pants in an unusual manner. If very pro- 
nounced, the symptom may be accompanied by some lividity of the lips, and 
pain about the chest. In advanced cases, where much dilatation has ensued, 
orthopncea may be present, and is a symptom of great gravity ; and some- 
times attacks of syncope are noticed. Palpitation is complained of in child- 
hood less commonly than in adult life ; but if the patient be anaemic, the 
heart's action may be tumultuous on slight exertion. Anaemia is a fre- 
quent consequence of the more aggravated forms of cardiac lesion. As in 
the adult, it is usually present if there be insufficiency of the aortic valves ; 
but even in this case it may not be noticeable as long as the child is kept 
quiet, A little girl lately under my care, with aortic and mitral regurgi- 
tation, always had a good colour as long as she remained in the hospital ; 
indeed, the healthiness of her complexion was the subject of remark by 
those who were acquainted with the serious lesion under which she was 
labouring. 

Hemorrhages sometimes occur. The nose may bleed repeatedly ; and 
in older children haemoptysis may be seen, especially if there be mitral 
stenosis as well as regurgitation. A little girl, aged twelve years, with 
mitral obstructive and regurgitant disease and great hypertrophy of both 
ventricles, frequently expectorated blood. The symptom would be prob- 
ably met with more frequently were it not for the childish habit of swal- 
lowing all sputa brought up from the lungs. Another common conse- 
quence of the pulmonary congestion induced by the valvular lesion and 
the resulting tendency to catarrh, is cough. This is usually short and hack- 
ing ; but if loose, for the reason stated is rarely accompanied by expectora- 
tion. When dilatation of the heart occurs, oedema follows quickly, and the 
disease then presents the same distressing features which are so familiar 
to every one in the case of the adult. 

An occasional accident is embolism. This is sometimes the conse- 
quence of ulcerative endocarditis, disintegrating particles of an infective 
organic matter being carried off into the circulation and deposited in va- 
rious organs, where they produce the consequences known to follow the 
presence of such infarcts. This complication, which is accompanied by 
high temperature and symptoms of blood contamination, has been already 
referred to (see page 158). It appears, however, that an ulcerative process 



548 DISEASE IN CHILDREN. 

is not necessary to the separation of portions of fibrinous matter from the 
valves. We occasionally meet with cases where a child, the subject of re- 
cognised heart lesion, but making no complaint and appearing to be little 
troubled by his infirmity, suddenly becomes paralysed on one side from 
obstruction of the middle cerebral artery. The symptoms which accom- 
pany the onset of the paralysis vary. The child may vomit repeatedly ; or 
be seized by convulsions followed by unconsciousness ; or pass into a state 
of delirium or even violent excitement. Sometimes the embolism takes 
place more quietly ; and nothing is noticed until it is found that the child's 
face is drawn, and that one side of the body has lost its power. 

A little girl, aged six years, had been subject for sixteen months to 
shortness of breath after any exertion, and at such times to blueness of the 
lips. She had never been known to have rheumatism ; but, six months 
before her admission to the hospital, had had an attack of measles, which 
had been followed by whooping-cough. There was a suspicious history 
pointing to syphilis, and the child was being treated by one of my surgical 
colleagues for keratitis. Her temperature was normal. 

On May 10th, the patient was noticed to be dull and apparently sulky. 
She passed her urine and faeces once involuntarily, which she had never 
done before ; and her temperature on that evening was 99.6°. On the 
next morning the mercury registered 99.4°, and the child's mouth was 
noticed to be drawn to the left side ; she could not stand ; her right arm 
was completely useless ; and her right eye closed imperfectly. In addition, 
she was aphasic. Although drowsy, she could be easily roused, and she 
took her food well, having no difficulty in swallowing. 

On examination of the heart, a loud systolic murmur was heard all over 
the front of the chest, and also at the back ; but it was louder on the left 
side, posteriorly, than on the right. In the left axillary region it was well 
heard, but became greatly diminished in intensity at the posterior axillary 
line. In front, the pitch of the murmur was highest at the base of the 
heart, and fell perceptibly towards the left nipple ; but in intensity of sound 
there was little difference between the nipple and the upper part of the 
sternum. The point of maximum intensity appeared to be the pulmonary 
valves. The apex beat was in the fifth interspace in the nipple line, and the 
right border reached nearly a finger's breadth beyond the right margin of 
the sternum. There was no clubbing of the fingers nor any signs of cya- 
nosis, at least while the child was at rest. That evening (May 11th) the 
temperature was 101.4°. 

On May 12th (the second day of the paralysis), the temperature was 
101.6° at 8 a.m., and rose in the evening to 103.8°. The incontinence of 
urine still continued, and the paralysis and aphasia remained the same. 
The child was perfectly conscious and intelligent, and tried in vain to 
speak. Her tongue, when protruded, deviated to the right side ; the right 
arm and leg were perfectly flaccid, and their sensibility was diminished. 
The muscles responded well to the interrupted current. The temperature 
fell somewhat on the third day of the paralysis, but remained more elevated 
than natural, in the evening, for several weeks, with occasional rises. Thus, 
on one or two occasions it suddenly rose to 102° ; and on one occasion to 
104°, in the evening, and then quickly became normal. During the child's 
stay in the hospital there was no sign of embolism of other organs. Her 
right leg rapidly improved, and she regained the power of walking ; but 
the arm continued powerless, and when discharged on August 14th, the 
patient was still unable to speak. 

In this girl there was doubtless a congenital lesion of the heart, consist- 






CHRONIC VALVULAR DISEASE OF THE HEART. 549 

ing in part of narrowing of the pulmonary artery, and, as a consequence, 
the right side of the heart had become hypertrophied. It is probable, 
also, that there was insufficiency of the mitral valve, from endocarditis 
occurring after birth ; and that it was from this source the embolus was 
derived, which had become arrested in the middle cerebral artery. 

In another case, a boy, aged eleven years, who was suffering from steno- 
sis and insufficiency of the mitral orifice, was taken suddenly with paralysis 
of the right side, combined with difficulty of speech, while recovering from 
an attack of small-pox. 

It is not always in the arteries of the brain that the embolus is arrested. 
The fragment may lodge in the kidney, producing albuminuria; in the 
liver, causing enlargement and slight jaundice ; and in the spleen, leading 
to perceptible swelling of the organ. In the latter case, according to Dr. 
Gee, the infarction is peculiarly liable to be associated with fever of the 
hectic type, without the endocarditis to which it is owing being necessarily 
ulcerative. 

There is one other result of embolism which may be noticed, although 
its consequences are not so immediately obvious. Aneurismal dilatations 
in the child are now known, from the researches of Dr. J. TV. Ogle and 
others, to be due to this accident. Aneurisms seated on the small arteries 
of the brain, leading to fatal hemorrhage, sometimes occur in young sub- 
jects, and are doubtless to be attributed to plugging of the vessel by this 
means. The same condition is also occasionally seen in the larger arteries, 
as the external iliac. 

Besides embolism, other occasional complications may be observed in 
cases of heart disease. On account of the rheumatic disposition of the 
majority of such patients, evidences of that constitutional state are often 
observable. Skin eruptions, especially eczema, erythema, and urticaria, are 
common ; pleurisy and pericarditis are not unfrequent lesions ; and joint 
pains are often complained of. Another common complication is some 
form of nervous derangement. Chorea is liable to occur in the subjects of 
heart disease ; and Dr. Sansom has remarked the occasional association of 
epilepsy with cardiac mischief. In some cases, impairment of nutrition is 
the only evidence of ill health. A little boy, aged seven years, was brought 
to the hospital with signs of mitral stenosis and insufficiency. Still, the 
boy had no cough, and did not appear to be breathless on exertion. For 
six months, however, he had been persistently wasting, although, with the 
exception of occasional abdominal pains, there was no evidence of digestive 
derangement, or other sufficient cause for the impaired state of his nutri- 
tion. In some cases the wasting is combined with anaemia, which may even 
reach an extreme degree. 

The most common form of heart lesion met with in childhood is regur- 
gitation through the mitral orifice. Next in order of frequency is regur- 
gitant combined with constrictive disease. Then follow a combination of 
constrictive and regurgitant disease of the aortic orifice, and constrictive 
disease alone. Stenosis of the mitral orifice, unaccompanied by insuffi- 
ciency of the valve, is not common in the child ; and regurgitation through 
the aortic orifice is far rarer than it becomes in after-life years. It will be 
unnecessary to describe the physical signs and special symptoms connected 
with these various lesions, since they do not, as a rule, present any peculi- 
arities dependent upon the early age of the patient. With regard, how- 
ever, to aortic regurgitant disease, it may be remarked that this form of 
heart lesion, as has been previously stated, is not always accompanied in 
the child by any striking pallor of the complexion ; nor is it often indi- 



550 DISEASE IN CHILDKENV 

cated by any marked alteration of the pulse. The pulse is regular, and is 
weakened by raising the hand above the head ; but the characteristic 
hammer-like beat of the artery is usually absent. Moreover, the pulsation 
of the more superficial vessels, although visible if narrowly looked for, is 
seldom sufficiently marked to catch the eye unsought. 

Terminations. — When death occurs in cases of heart disease, during 
childhood, the fatal event is often brought about by some inflammatory 
complication. Children so afflicted are more weakened than is the case 
with a healthy subject, by casual derangements, and have less vigour with 
which to bear up against a serious disease. When death is due directly to 
the heart lesion, it generally occurs in cases where the pericardium has 
become firmly adherent to the substance of the heart, and has led to serious 
interference with the nutrition of the organ. The cavities become greatly 
dilated, and the feeble walls are no longer equal to the discharge of their 
functions. Great congestion of the lungs follows, and there is general 
stasis of blood in the systemic venous system, with its inevitable conse- 
quences. In most cases of death from cardiac dropsy, the pericardium is 
found firmly adherent to the heart. 

Sudden death is not very common from cardiac lesion in the child. When 
it takes place it is probably the result of clotting of blood in the large ves- 
sels of the heart. A little girl was under my care in the East London 
Children's Hospital for chorea, which had followed closely upon an attack 
of sub-acute rheumatism. The child was low and depressed, and her com- 
plexion was markedly anaemic. The choreic movements were bilateral, 
affecting the face, tongue, and eyes, but were only moderate in degree. 
When she took food into her mouth, the muscles of deglutition acted con- 
vulsively. On examination of the heart there was a loud bellows murmur 
at the apex, conducted well into the axilla. This evidently datecl from 
some previous attack of rheumatism. During the girl's stay in the hos- 
pital, fibrous nodules were developed on the tip of each spinous process of 
the vertebras. The child was treated at first with chloral ; afterwards, with 
quinine and iron. She took three ounces of port wine daily. In spite of 
the treatment, she wasted, and seemed to grow weaker. After a time, as 
no improvement occurred, the patient was removed by her friends ; and we 
afterwards heard that she died quite suddenly on the following day. No 
post-mortem examination was obtained. 

Sometimes the clotting takes place more slowly. A little boy, suffering 
from mitral regurgitant disease, with much dilated hypertrophy of the left 
ventricle, was noticed for two days to be uneasy and restless, with some 
dulness of manner. On the third day he was seized with dyspnoea, which 
became gradually more severe. The child grew excessively restless, and 
threw himself about in his bed. When I saw him (at 3 p.m.) he was sitting 
up in bed, supported by the nurse. His eyes were staring and wild-look- 
ing, his face much congested, his lips and cheeks purple, his finger-nails 
blue. The breathing was laborious, and the nares acted. The heart's ac- 
tion was excited and forcible, but the pulse at the wrist was excessively 
weak. The boy was very restless, constantly changing his position and 
throwing his arms about. He was quite sensible, and made no complaint. 

Six leeches were applied to the region of the heart. They bled freely, 
but the symptoms continued, the lividity deepened, and the boy died in a 
few hours. No examination of the body was allowed ; but there can be 
little doubt that death was occasioned by ante-mortem clotting in the 
heart or large vessels near their origin. 

Diagnosis. — The existence of a valvular lesion of the heart is ascertained 



CHRONIC VALVULAR DISEASE OF THE HEART. 551 

almost as readily in the young subject as it is in the adult. Even if a 
child cry during the examination of his chest, the heart sounds can usually 
be perceived during the short interval of inspiration. In most cases, how- 
ever, if the patient be not frightened by abruptness of movement, and if 
he be allowed to play with the stethoscope before the instrument is applied 
to his chest, a young child will submit to the process of auscultation with- 
out any complaint. 

When a murmur is detected, we have to decide if it be of recent origin. 
A recent murmur is soft and of low pitch ; but as time goes on it becomes 
harsher and its pitch rises. If the lesion affect the calibre of the orifice at 
which it is generated, or interfere with the closure of the valves, it soon 
leads to some enlargement of the heart and alteration in the position of 
the apex-beat. If, in a child who is suffering from acute or sub-acute 
rheumatism," we detect a harsh, high-pitched, systolic murmur at the apex, 
we may conclude that the cardiac lesion dates from a period considerably 
anterior to the existing illness. In noting the position of the apex-beat, 
and its relation to the nipple, it is important to remember that in many 
children the nipple lies at a lower level in the chest than is the case in the 
adult. Instead of the fourth rib, it is often placed on the upper border of 
the fifth. In such a subject the normal position of the apex-beat would be 
in the fifth interspace just below the nipple and slightly to its inner side. 

In every case of indisposition in the child, however apparently trifling 
it may seem, the heart should be carefully examined, for, as has been said, 
a valvular lesion may be present without giving rise to symptoms of dis- 
comfort, and evidence of disease is sometimes found very unexpectedly. 
There are, however, certain combinations of symptoms which should at 
least excite suspicion. Attacks of palpitation in the child are less com- 
monly than in the adult the consequence of functional derangement or 
dyspeptic disorder, and, if present in a marked degree, should suggest 
cardiac mischief. Frequent epistaxis in an anaemic child is not uncom- 
monly the result of mitral disease ; and if a child who is not ana?mic 
becomes breathless after exertion, especially if the shortness of breath is 
accompanied by lividity of the lips, the symptom should excite the strongest 
suspicions. 

The presence of a murmur at the apex is not in itself sufficient evidence 
of a serious lesion. Heart murmurs in children not uncommonly disappear. 
This statement is true not only of recent soft murmurs, such as are heard 
in cases of chorea or acute rheumatism, but also of louder and harsher 
murmurs which are known to be of longer duration. In all cases where a 
harsh murmur is detected, signs of hypertrophy of the left ventricle should 
be searched for. If no enlargement be discovered, and the apex-beat re- 
main in its normal position, it is highly improbable that any serious val- 
vular defect is present, (see page 163). The apex-beat of the heart may, 
however, be in an abnormal position without the alteration in site being 
the result of endocardial disease. The causes which lead to displacement 
of the organ are referred to elsewhere (see page 402). 

Again, a basic heart murmur may be produced by causes acting from 
without. Pressure upon the large vessels by caseous bronchial glands 
may so narrow the channel as to give rise to a systolic murmur. In these 
cases, however, other signs will be found, explanatory of the abnormal 
phenomenon (see page 181). 

The detection of a cardiac murmur will sometimes furnish an explana- 
tion of symptoms which would be otherwise obscure. In all cases where 
hemiplegia occurs suddenly in a child, attention should be at once directed 



552 DISEASE m CHILDBED. 

to the heart. But mere pyrexia is sometimes caused by embolism in other 
organs, where irritation and disturbance give rise to less characteristic 
symptoms than are found when a portion of brain is suddenly rendered 
useless. In cases of ulcerative endocarditis, continued high temperature, 
and a condition bearing a close resemblance to enteric fever, may be in- 
duced by the accident ; but even when the fragments of organic matter 
thrown off from the valves have not this infective character, an irregular 
pyrexia may be set up. Careful search in these cases will often discover 
some local symptoms suggestive of the presence of an infarct. The spleen 
may be found to be swollen ; the liver may be enlarged, with slight jaun- 
dice ; albuminuria may occur from embolism of a kidney ; or petechise 
may be noticed in the skin from obstruction to the circulation through the 
cutaneous capillaries. In all these cases the source of the mischief will be 
discovered on examination of the heart. 

Prognosis. — As long as the cardiac lesion gives rise to no symptoms, the 
prognosis is very favourable. If a mitral murmur, although harsh in qual- 
ity and high in pitch, be accompanied by no signs of hypertrophy of the 
left ventricle, there is reason to hope that it may ultimately disappear. If 
signs of enlargement of the heart are noticed, we cannot expect that the 
valvular lesion will be recovered from ; for a temporary dilatation of the 
left ventricle, such as is apt to occur in chlorotic girls, I do not think is 
common in the child ; but as long as the health of the patient seems to 
suffer in no way from the disease, little apprehension of immediate danger 
need be entertained. Directly, however, any symptoms are .noted indi- 
cating impairment of nutrition or obstruction to the circulation, there is 
cause for anxiety. Serious breathlessness, lividity on slight exertion, 
marked anaemia and perceptible loss of flesh, are all unpromising symptoms. 

The prognosis is more favourable in cases of mitral insufficiency than 
of mitral stenosis. If the mitral disease has led to tricuspid insufficiency, 
speedy dilatation of the cavities of the heart may be anticipated. When 
signs of dropsy begin to be perceived, the danger is really imminent. By 
judicious treatment and careful nursing the end may be postponed, but 
cannot in any case be far distant. 

Attacks of rheumatism and chorea, being apt to aggravate the valvular 
lesion, are greatly to be dreaded ; and all forms of inflammatory chest 
affection, as they increase the work of the heart, are likely to have injurious 
consequences. Embolism is a very serious accident. If the embolus 
lodge in the middle cerebral artery and produce hemiplegia, the complica- 
tion, although it may not destroy life, may lead to permanent impairment 
of movement of the limbs. In the second of my cases of cerebral embolism 
referred to above — a boy eleven years old — the patient, two years after the 
attack of paralysis, had very little use of the right arm. He could walk, 
however, and had recovered the power of speech. If the brain be un- 
affected, and the embolism occur in other organs, the resulting irritation 
and disturbance may prove fatal, even although the fragment detached 
from the valve be destitute of any infective property. 

Treatment. — In cases where a valvular lesion exists without producing 
any sign of inconvenience, there is no reason for special medication. The 
parents should, however, be cautioned to spare the child all unnecessary 
fatigue, and to prevent him as much as possible from taking part in violent 
exercises. Excitement of the heart should be prevented. In the case of 
a schoolboy this is, of course, a matter of great difficulty ; for, as long as 
the child is untroubled by uneasy sensations, he cannot be convinced of the 
necessity for quiet. Little girls are fortunately less addicted to boisterous 



CHROXIC VALVULAR DISEASE OF THE HEART. 553 

games. Measures should be taken to prevent fresh attacks of rheu- 
matism, and the child should wear woollen underclothing all the year 
round. 

Directly palpitations, breathlessness after exertion, or ansemia, begin to 
be noticed, more active measures must be taken. Too energetic action of 
the heart must be quieted by digitalis. This valuable drug has always 
seemed to me to be well borne by young patients. The best form in which 
it can be given is the infusion, of which a child of ten years iAd will take, 
without any inconvenience, two drachms three times in the day. On ac- 
count of the importance in these cases of keeping up a gentle action of the 
bowels, I usually combine the remedy with a mild aperient and a vegetable 
bitter. One drachm each of the infusions of digitalis, senna, and calumba, 
given three times a day before meals, is often followed by great benefit ; 
or, if desired, the proportion of digitalis may be doubled. If the diges- 
tion is weak, a few drops of dilute nitric acid may be added to the 
draught, When any signs of anaemia are present, iron should be given 
in addition. This medicine is best administered separately, and I pre- 
fer the exsiccated sulphate in these cases to all other forms of iron. Four 
or five grains of the salt may be given in glycerine directly after each 
meal. 

Great care is necessary in the matter of diet. The child is not to be 
overloaded with food because he is weakly and seems to be losing flesh. 
His meals should be small, that his stomach may not be oppressed ; and the 
quantity allowed should be such as his digestion can bear and his tissues 
readily assimilate. If the blood be overcharged with superabundant 
material which is useless for purposes of nutrition, extra work is thrown 
upon the excretory organs, whose duty it is to eliminate it from the system. 
It is well to order four small meals in the day, of which one may consist 
of meat with vegetables, a second of a piece of fish or an egg, and the two 
others of milk and bread and butter. The quality of the food should be 
also attended to. AH rheumatic subjects have a special tendency to flatu- 
lence and acidity ; and this tendency is favoured by excess of starchy mat- 
ters and sweets. It is often remarkable to note the immediate improve- 
ment which takes place in the condition of a child who has been pampered 
and overfed " because he is delicate," when these simple rules are at- 
tended to. 

When dilatation of the heart occurs, and leads to stasis of blood in the 
systemic veins and general oedema, diuretics are' indicated. This condi- 
tion must be treated in the child upon the same principles as are followed 
in the case of the adult. The kidneys must be stimulated to act by the 
acetates of potash and ammonia, spirits of nitrous ether, juniper, fresh 
broom tops, squill and digitalis. One especially valuable diuretic in these 
cases is the tincture of cantharides. I have seen a formidable amount of 
dropsy clear away completely in a child of nine years old under the influ- 
ence of ten drops of this remedy given three times a day, after other 
means had been used without making any impression upon the effusion. 
I have tried the resin of copaiba, but the drug has proved of little service 
in my hands. Drs. Leech and Brackenridge speak highly of the value of 
caffein. The action of diuretics is greatly aided by dry-cupping the region 
of the kidneys, and afterwards applying a succession of hot linseed-meal 
poultices to the loins. For aperients, I prefer the compound jalap powder 
to elaterium, which has a very uncertain action on the child. Stimulants 
are of service, and unsweetened gin may be given in suitable doses as re- 
quired. If it be necessary to puncture the legs, Dr. Southey's cannuhe 



554 DISEASE IN CHILDREN. 

should be employed ; and Dr. Goodhart's suggestion that these instru- 
ments should be steeped in some boiling germicide before being used, is 
one of distinct practical value. 

When embolism occurs in a cerebral artery, producing hemiplegia, the 
bisulphite of soda may be given in doses of ten or fifteen grains three 
times a day. This drug has a marked action in rapidly relieving the 
phlebitis which is so common in women lately delivered ; but my experi- 
ence is too small to enable me to speak confidently of its value in the 
cases above referred to. 



Part B. 
DISEASES OF THE MOUTH AND THROAT 



CHAPTER I. 

THE DERANGEMENTS OF TEETHING. 

The period of active development of the milk teeth is always a time of 
trial for the young child. Many an infant seems healthy and sturdy up 
to this point ; but when the time of teething arrives his nutrition falters 
and he begins to fail. On this account mothers, if they do not look upon 
the eruption of the teeth as a disease in itself, are at least in the habit of 
attributing every complaint which occurs during the first two years of life 
to the influence of this normal physiological process. In the medical pro- 
fession the views held with regard to the influence exercised by teething 
upon the infant economy were at one time very similar. At the beginning 
of this century, dental development was looked upon as one of the chief 
causes of death in the infant. One author classes it amongst the fatal dis- 
eases of childhood. Others estimate the mortality from this cause at one- 
tenth, one-sixth, one-third, and even one-half of the whole number of 
deaths under the age of two years. Even in the present day it is common 
to find dentition included in the etiology of almost every variety of nervous 
disorder occurring in the child. 

The period of dentition coincides with that of the most active physical 
progress. Towards the end of the first year of life the follicular apparatus 
of the intestines is undergoing considerable development ; the cerebro- 
spinal system is passing through a stage of rapid growth and high func- 
tional activity ; and most organs and tissues of the body are in a state oi 
active change. The evolution of the teeth is not, therefore, a solitary in- 
stance of developmental progress, but corresponds to a similar activity of 
growth in other parts. No doubt, a period, such as this, of quick transi- 
tion is a period of exceptional susceptibility. Derangements of function 
are very liable to occur ; but to attribute these exclusively to one of the 
many physiological processes of which the body is the seat, merely because 
this process is external and visible to the eye, while the others are inter- 
nal and cannot be seen, is to generalize hastily, and from very insufficient 
data. 

There is another reason why, at the time of teething, various forms of 



556 DISEASE IN CHILDBED. 

illness are liable to arise. The stomatitis so commonly induced by the 
advance of a tooth in the gum, is a cause of pyrexia. A feverish child is 
very susceptible to chills, and is liable to be disordered by the irritating 
influence of unsuitable food. In such a state, also, the digestive power of 
the infant is weakened, so that the food on which he has been thriving 
may cease to agree. Derangements of the stomach and bowels, thus in- 
duced, if prolonged as they often are by improper treatment, cause serious 
interference with nutrition and not uncommonly bring the infant to the 
grave. To say, however, that in such a case the child dies from teething, 
is incorrect. He dies from mal-nutrition, brought on by persistence in 
forcing upon him food which is no food, because he cannot digest it. His 
diet, instead of supplying him with the nourishment he requires, ferments, 
turns acid, and sets up catarrhal diarrhoea ; so that at last he succumbs, 
worn and exhausted by purging and starvation. The looseness of the 
bowels, which is so apt to occur during the period of teething, cannot be 
attributed with any justice directly to the process of dentition. The fever- 
ish child is attacked by intestinal catarrh, because his body for the time 
is more than usually susceptible to the influences which are capable of ex- 
citing that derangement ; but teething is the cause, not of the purging, but 
of the fever. So, also, in the case of pulmonary catarrh, which in some 
subjects is a common accompaniment of the eruption of each separate 
tooth, it is to the pyrexia, and not to the accidental cause of the pyrexia, 
that the derangement is to be ascribed. In support of this view, it maybe 
remarked that diarrhoea is a more common complication of dentition dur- 
ing the warmer months, when the weather is liable to sudden and unex- 
pected changes, and the temperature varies rapidly while the dress of the 
child remains the same ; and is less common during the winter, when more 
care is taken to guard the child's body from the cold. Again, the pulmo- 
nary accidents are more common in raw, damp weather, at the times when 
such disorders are especially apt to prevail. 

On account of the early age of the infant, and for the reasons which 
have been given, the first dentition is more liable than the second to be ac- 
companied by serious disturbances ; but even in cutting the second crop 
of teeth, digestive troubles are likely to occur, as will be afterwards de- 
scribed. 

The first dentition begins under normal conditions in the middle of the 
first year, and ends toward the beginning of the third. The eruption of 
the milk teeth may, however, be anticipated or delayed through individual 
peculiarity, or some abnormal constitutional state. Thus, cases occasionally 
occur in which the child is found to have a tooth when he is born. Such 
teeth are usually sharp and hook-shaped, and are often loose, consisting 
merely of the crown of the tooth embedded in a fold of the gum.. Henoch 
has described another variety of congenital tooth, which is firmly fixed in 
the socket. The tooth is destitute of enamel, and looks yellow, with a 
rough surface. Henoch attributes the eruption to a periostitis of the al- 
veolar border, which pushes the rudimentary tooth outwards by swelling 
and exudation within the socket. 

It is not uncommon for teeth to begin to be cut at the third or fourth 
month ; but in such cases the eruption of one or two teeth is usually fol- 
lowed by a pause, and the continuance of the process is deferred until the 
usual age. In certain states of the constitution, dentition is early. Thus, 
children with tubercular tendencies, or who suffer from a syphilitic ca- 
chexia, cut their teeth early, as a rule. In rickets, on the contrary, denti- 
tion is always late, and in exceptional cases no tooth may appear until the 



DERANGEMENTS OF TEETHING. 557 

end of the second or beginning of the third year. Ordinary malnutrition, 
when the child has not become rickety, does not interfere with the evolu- 
tion of the milk teeth. In chronic diarrhoea, when the child is very weakly, 
and much wasted by constant purging, I have often noticed with surprise 
that the natural evolution of the teeth has been in no way retarded by the 
distressing complaint. 

In an ordinary case the milk teeth appear in the following order : — 
Lower central incisors, upper central incisors, upper lateral incisors, lower 
lateral incisors, first molars, canines, back molars. Of these the first 
should appear between the seventh and ninth month. At twelve months 
old the infant should have cut eight teeth, and the four first molars should 
be in process of evolution. He should cut his eye-teeth (canines) between 
the sixteenth and twentieth month ; and the whole number of the first 
crop (twenty) should have pierced the gum soon after the end of the second 
year. The teeth are usually cut in pairs ; and after the completion of 
each group there is usually a pause before the evolution of the next group 
begins. 

The order given above, although that which most commonly obtains, 
is yet often departed from in children whose health is perfectly good. 
Many babies cut their teeth "cross," as it is called. The lateral incisors 
sometimes appear before the central front teeth ; the first molars may 
precede the lateral incisors ; the last molars may precede the canines ; and 
in a few instances I have seen a canine tooth cut before any of the first mo- 
lars have appeared, but this last exception is a very rare one. Sometimes 
in rickety children, when dentition is greatly retarded, the first tooth to 
appear is one of the first molars. Thus, a rickety little boy under my care 
cut his first tooth — one of the first molars — at the age of two years. An- 
other cut his earliest tooth — also a first molar — at fifteen months. 

Although the full number of the milk teeth when dentition is completed 
is twenty, this number is not always reached. It may happen that certain 
teeth never appear at all. Thus, a little girl under my care, aged two 
years and nine months, was seen to have all the milk teeth except the two 
upper lateral incisors. On the left side there was a narrow space re- 
maining between the left middle incisor and the canine ; but in this space 
-the gum was sharp, and there was no sign of a tooth. On the right side, 
the right central incisor and the adjoining canine were in contact. In the 
same way I have known the whole four canines to be absent. In some 
cases the peculiarity is a hereditary one. In a case which came under my 
notice the left lower lateral incisor was wanting in a little girl of two years 
old. The same incompleteness of the milk teeth had occurred in the 
mother, This lady had three other children — all boys — whose early den- 
tition had presented no deviation from the normal type. It is certainly 
curious that the irregularity which had occurred in the mother should 
have been reproduced in the only one of her children whose sex was the 
same as her own. It is important to be aware that incompleteness of the 
first crop of teeth does not necessarily imply that a similar irregularity 
will be met with in the second. Mr. Tomes, in his work on dental surgery, 
refers to the case of a little girl who cut none of her milk teeth, but in 
whom the permanent set appeared as usual. Sometimes, instead of too 
few, too many milk teeth are developed. A little girl between two and 
three years old lately came under my notice who had five perfect incisors 
in the lower jaw. 

The process of dentition is much easier in some children than it is in 
others ; but it is difficult to assign a reason for these differences. The fa- 



558 DISEASE IN" CHILDEEN. 

cility with which the teeth appear seems to be dependent more upon indi- 
vidual peculiarity than upon actual bodily health. Teeth cut early are not 
always cut easily ; and delayed dentition is not always, nor even usually, 
troublesome. A perfectly healthy child may cut his teeth with much suf- 
fering, although fully up to time ; while a rickety child, although very 
late in teething, may suffer no inconvenience at all in the process. 

Symptoms. — The symptoms which accompany the eruption of the milk 
teeth are very variable. Sometimes no signs at all are noticed, and noth- 
ing is known of the matter until accident discovers the presence of a tooth 
through the gum. Usually, however, the infant is restless and irritable ; 
he flushes and is feverish. A copious secretion of saliva occurs, and the 
child " dribbles," the fluid flowing from his lips over his chin. At night 
he is disturbed in his sleep, and in the daytime may be noticed suddenly 
to give a little cry, or contract his features as if in pain. He also makes 
" munching " movements with his jaws, sucks his lips, and gives every indi- 
cation of uneasiness in his gums. Most writers on this subject, following 
Hippocrates, describe a painful itching sensation of the gum, which is said 
to be present in these cases, and whether or not the sensation is correctly 
described as an itching, there is no doubt that it causes distress, and ap- 
pears to be relieved by gentle frictions with the finger or any other smooth 
object. On examining the mouth, the gum is found to be swollen and 
cushiony, and sometimes, shortly before the tooth appears, is very tense 
and hot. At this time, friction, which before was pleasant, becomes very 
painful. The gum is evidently tender, and the child may be sometimes 
seen to hold his mouth half open, as if he feared to close his jaws. All the 
symptoms subside when the tooth pierces the gum. 

The pyrexia of teething is very irregular. It is often higher in the 
morning than at night, and is liable to rapid variations. Thus, a little 
boy, aged fifteen months, had eight teeth, and was cutting his left lower 
molar. At 6 a.m. his temperature (in the rectum) was 99°. At 10 a.m. it 
had risen to 103.8° ; and at 10 p.m. was 102.2°. It gradually fell during 
the night (being taken every four hours), and at 10 a.m. on the following 
morning was 100°. It then rose again to 102° at 6 p.m. ; fell to 98° at 2 
a.m. (third day), and at 10 a.m. stood once more at 103.8°. A good dose of 
castor oil was then given, and the temperature at once became normal. 

In a teething infant the mercury often registers 104° at 8 or 9 a.m. ; 
indeed, in a young patient such an amount of fever in the morning is alone 
a circumstance of great suspicion, and should at once lead iis to examine 
the state of the gums. Few diseases, at this early age, cause so much pyrexia 
at this period of the day. 

The symptoms which have been enumerated do not necessarily herald 
the immediate appearance of the tooth, but will be often found to come 
and go — waxing and waning in severity, and sometimes subsiding alto- 
gether, so that the infant passes through alternate periods of suffering and 
ease for some days, or even weeks, before the tooth comes through the gum. 
Usually, more distress is experienced during the eruption of the canine 
teeth than at any other period of dentition. 

Complications. — The symptoms just described may be looked upon as 
natural to the process of teething. In many cases, other symptoms are 
noticed, expressive of derangements which do not follow naturally from the 
evolution of the teeth. They^ arise as accidental troubles, and must be 
attributed to the ordinary causes of ill health acting upon a body in a state 
of irritation and fever, and therefore peculiarly susceptible to their influ- 
ence. These are stomatitis and aphtha? ; repeated vomiting or diarrhoea, 



DERANGEMENTS OF TEETHING COMPLICATIONS. 559 

more or less prolonged, from catarrh of the stomach or bowels ; cough 
from pulmonary catarrh ; otitis ; various forms of skin disease, and cer- 
tain troubles of the nervous system, such as squinting, convulsions, etc. 

The stomatitis is of the simple form, as a rule, and consists of an erythe- 
matous redness of the mucous membrane of the gums over a considerable 
area. The affected gmms are somewhat swollen, and are hot and tender to 
the touch. If the tenderness is great, the child may refuse to suck the 
bottle or its mother's breast. High fever always accompanies this compli- 
cation. The ulcerative form of stomatitis is also sometimes present, and 
has the characters described in the following chapter. 

Attacks of vomiting and diarrhoea, from acute gastric and intestinal 
catarrh, are common in teething children. For the reasons which have 
been stated, infants, whether teething or not, are at all times liable to ready 
disturbance of indigestion ; indeed, at this age, digestive troubles form a 
large proportion of their ailments. Therefore, vomiting is especially apt 
to occur when the stomach is irritable and weak from pyrexia, unless the 
child's diet be promptly modified to suit the altered state of his digestive 
organs. In the same way, whether from the irritation of undigested food, 
or the sensitiveness of the heated body to even trifling variations of the 
external temperature, purging of a mild character is a very common symp- 
tom. If the teeth are cut in rapid succession, a looseness of the bowels 
may prevail to a greater or less degree during the whole period of denti- 
tion. If this looseness remains confined within moderate bounds, it may 
do no apparent harm to the patient ; but it should not on that account be 
allowed to continue, for at any time a severe attack of inflammatory diar- 
rhoea may supervene, with not improbably fatal consequences. This serious 
accident is especially liable to occur in hand-fed babies, who, while they 
are suffering from intestinal irritation, are naturally more than commonly 
sensitive to the disturbing influence of undigested food. The ordinary 
diarrhoea of teething consists of green or yellow matter, with smaU lumps 
of curd. It is often passed with straining, and its passage is preceded by 
griping pains. 

In cases of chronic diarrhoea, the influence of teething is often distinctly 
pronounced. The irritation of the gum set up by the advancing tooth 
tends to maintain an irritable state of the bowels, so that, although the act- 
ual purging may be readily kept under control, an intolerance of milk and 
the fermentable articles of food continues to prevail, and is very difficult to 
overcome. Often in such cases, in spite of the most careful dieting, attacks 
of looseness are frequent ; the child remains weak and low, and seems to 
make no progress towards recovery. "When, however, the tooth appears, 
and a pause occurs in the process of dentition, immediate improvement is 
noticed; the motions become healthy, and flesh and strength begin to re- 
turn. 

Pulmonary catarrh, with a hard cough, is a common complication of 
teething ; and the high fever by which these attacks are accompanied may 
cause great anxiety, as it gives a false appearance of gravity to what is 
really a trifling ailment. The child coughs a more or less hard cough, 
which may even have a " croupy " sound ; his nares dilate in inspiration, 
and the breathing is hurried. His mouth is hot and dry, and dribbling, 
if it had been previously noticed, ceases when the fever begins. The child 
is very irritable and restless ; his tongue is furred, and his bowels are 
confined. The catarrh is usually relieved by appropriate remedies ; but if 
care be not taken, and the child be exposed to cold or draught, a really se- 
vere bronchitis or broncho-pneumonia may be induced. 




560 DISEASE IN CHILDREN. 

Otitis is a not uncommon accident at this period. Dr. Woakes has ex- 
plained the mechanism by which inflammation of the middle ear is pro- 
duced. Irritation is conveyed from the inflamed gum to the otic ganglion, 
and is then deflected to the vessel supplying the tympanic membrane. As 
a consequence, this membrane becomes acutely congested, giving rise to 
severe pain ; and if the irritation persist, it may lead to inflammation and 
suppuration within the tympanic cavity. The membrane soon becomes 
perforated, and a purulent discharge issues from the external auditory 
meatus (see otitis). 

The forms of skin disease which are liable to arise in teething infants 
are the erythematous rashes and eczematous eruptions. The former are 
usually transient, and readily subside ; but the latter may spread over the 
greater part of the body, putting the child to the greatest distress from 
constant itching, and obstinately resisting treatment. 

Of the nervous disorders which are apt to occur at this period it is very 
difficult to say how far they are due to the actual process of teething, or to 
what degree the rapid development of the cerebro-spinal system is answer- 
able for these accidents. In some impressionable infants a very tense, 
swollen gum may, I believe, like any other variety of irritation in any part 
of the body, be sufficient to induce an eclamptic attack. In many cases the 
convulsion is probably to be ascribed to otitis, set up by the state of the 
gum. Trousseau has suggested that a high degree of fever may be in it- 
self a sufficient cause for the nervous trouble ; but I have never met with 
a case of convulsions in the child which I could attribute to this cause alone ; 
for the initial convulsion, which is so common at the beginning of many 
acute diseases in early life, is probably owing to other causes than mere 
elevation of temperature. It is easy to understand that an excitable infant, 
whose whole nervous system is in a state of disquiet from pain, disturbed 
sleep, and continued dental irritation, may have convulsions induced b}^ a 
very slight additional stimulus. In such a child a lump of indigestible 
food, or a scybalous nodule in the bowels, may increase the irritation to an 
irresistible degree, and it is probable that some such secondary cause often 
has a share in the production of the eclamptic seizure. 

In the second dentition, the order in which the teeth appear is more 
regular than in the case of the first. The eruption of the permanent teeth 
begins between the ages of five and a half and seven years with the ap- 
pearance of a permanent molar behind the last of the temporary teeth. 
Next come the central incisors about the eighth year ; the lateral incisors 
at about the ninth ; the first and second bicuspids in the place of the 
temporary molars at the tenth and eleventh ; the canines between the 
twelfth and thirteenth, and the second molars at about the time of 
puberty. The last four permanent molars are cut later. The only excep- 
tion to the above sequence that I have noticed is that in rare cases the 
eruption of the central incisors precedes the appearance of the early molars. 

In certain exceptional cases the milk teeth have been known to be re- 
tained into adult life. Some years ago Mr. Napier showed at a meeting of 
the Eoyal Medical and Chirurgical Society the cast of the mouth of a young 
lady of twenty-five in whom the milk teeth were still retained, with the ex- 
ception of the upper central incisors. The same abnormality had occurred 
in the case of the lady's sister, and it had been also noticed in one of the 
mother's relatives. 

The beginning of the second dentition in delicate children is often 
accompanied by signs of gastric or intestinal irritation. The child seems 
very sensitive to changes of temperature, and is subject to attacks of loose- 



DERANGEMENTS OE TEETHING— DIAGNOSIS — TREATMENT. 561 

ness of the bowels. He is often irritable and restless ; looks pale, with 
dark circles round his eyes, and sleeps badly at night. His stools often 
contain mucus in large quantities. Such children are very liable to the 
so-called "night terrors," which in all cases, so far as my experience has 
extended, are merely attacks of nightmare, the consequence of indigestion 
and acidity, and can be at once arrested by diet and suitable treatment. 
If, however, care be not taken to modify the child's diet to suit the degree 
of digestive weakness, the derangement continues and the patient begins 
to lose flesh ; indeed, in some cases a great degree of emaciation is 
reached. 

Diagnosis. — The clinical importance of the first dentition consists in 
the frequency with which the process is found to complicate all the various 
derangements and diseases to which infancy is liable. The pyrexia in- 
duced by teething often infuses an element of obscurity into a case which 
would otherwise present little difficulty. In infants we must be always 
prepared for this source of confusion, and should never forget to ascertain 
the state of the gums before bringing our examination to a close. 

In the case of pulmonary catarrh attacking a teething child, the com- 
bination of fever with cough, rapid breathing and active nares, suggests 
the presence of pneumonia. It will, however, be noticed that the child 
does not look ill ; his cough is looser and less hacking than the cough of 
pneumonia ; his pulse-respiration ratio is not perverted, and the history 
is not that of inflammation of the lung. In searching further for a cause 
for the pyrexia, the gums will be noticed to be tense and swollen, and the 
source of the fever is immediately explained. We must not, however, in 
all cases where the gums are hot and uneasy, at once conclude that they 
are the sole cause of the symptoms noticed. It sometimes happens that 
serious cerebral disease occurs in a teething child ; and if, mistaking their 
nature, we attribute the nervous symptoms to dental irritation, we make a 
mistake which the friends of the patient are not likely readily to forget. 
Therefore, nervous symptoms occurring in the course of teething must in 
every case receive careful attention. Headache, mild delirium, vertigo, 
startings, twitches, and convulsive attacks are so commonly the conse- 
quence of general nervous disturbance from any cause, that they have 
lost all claim to be considered special manifestations of cerebral disease. 
If, however, the bowels become obstinately confined, the pulse slow and 
irregular, the breathing unequal and sighing ; and if, in addition to these 
suspicious symptoms, we notice that the child frequently frowns and avoids 
the light ; that he is sullen and drowsy, lies with his eyes half closed, and 
screams out suddenly as if in pain, we have every reason to fear the occur- 
rence of tubercular meningitis. Li all doubtful cases the effect of a mild 
aperient should be tried. Castor oil brings rapid relief in most of the dis- 
turbances of a teething child. Therefore, if the nervous symptoms disappear 
after the operation of this simple remedy, their purely functional origin is 
at once apparent. 

In the case of diarrhoea from intestinal catarrh occurring in a teething 
child, there is not the same source of fallacy as in the other complications, 
for in ordinary cases looseness of the bowels at once causes pyrexia to 
subside. 

Treatment — The derangements which occur during dentition must be 
treated upon ordinary principles, and the reader is referred to the various 
chapters devoted to these derangements for information upon this subject 
It may, however, be remarked that it is especially important in a teething 
child to keep the belly warm, and to avoid all sources of chill. Also, that 
36 



562 DISEASE IN CHILDEEN. 

it is essential, in all cases where signs of gastric or intestinal disturbance 
are noticed, to reduce at once the quantity of fermentable food which is 
being taken, as fermentation and acidity are the earliest consequences of 
the catarrhal derangement. In cases of diarrhoea there should be no hesi- 
tation about arresting the looseness as quickly as possible. A dose of 
castor oil should be given ; and if the purging do not cease after the action 
of the aperient, it will yield readily to bismuth (gr. v.-x.) with aromatic 
chalk powder (gr. v.), or to one-grain doses of oxide of zinc. If fever is 
high, or the gum seems to be especially painful, great relief will follow an 
aperient dose of castor oil. This at once reduces the pyrexia and calms the 
tension and uneasiness of the gum. The irritation of the swollen and in- 
named gum may be reduced almost immediately by rubbing the afflicted 
part with the finger, moistened with fresh lemon-juice. Some smarting is 
at first excited by the application, and the child's wailings are increased ; 
but after a few minutes the smarting subsides, and with it disappears much 
of the discomfort previously experienced. This practice is common, I 
am told, amongst the native nurses in the Cape Colony. 

The practice of lancing the gum, which at one time was looked upon as 
a sovereign remedy for all the disorders incident to the period of teething, 
has now but few supporters. The only condition for which I should feel 
inclined to have recourse to it is that in which convulsive attacks occur in 
a child whose gums are very tense, swollen, and tender. In such a case, 
where it is our object to remove all sources of irritation, the gums may be 
lanced freely with advantage. Lancing the gums with any view of there- 
by hastening the evolution of the tooth below, is, of course, putting the child 
to very unnecessary pain. 

If, during the second dentition, signs of digestive disturbance are noticed, 
and the child looks pale and begins to waste, and especially if the symptoms 
called "night terrors" are noticed, the bowels should be acted upon by a 
mild aperient every three or four days ; the diet should be regulated, re- 
stricting the quantity of farinaceous food and sweets (especially forbidding 
potatoes, puddings, cakes, and fruit), and the child may take six or eight 
grains of bicarbonate of soda two hours after each meal. I have never seen 
a case of "night terrors" which has resisted this treatment 



CHAPTEE II. 

STOMATITIS. 

Infants and young children are very liable to derangement of the mu- 
cous membrane lining the interior of the mouth. Partly on account of the 
irritation of the gums resulting from dentition, partly on account of the 
ready sympathy which exists between the membrane lining the buccal cav- 
ity and that of the digestive apparatus with which it is continuous, an in- 
flammatory condition of the mouth is a common disorder. In a healthy 
child the lesion produces little more than passing discomfort, and readily 
subsides. In a cachectic or weakly subject the derangement may be more 
serious, and in some cases the inflammation passes into severe ulceration 
or even gangrene. 

The simple form of stomatitis, which is often a complication of teeth- 
ing, has already been described. In the present chapter two other varie- 
ties of disease resulting from, inflammation of the mucous membrane will 
be considered, viz., aphthous or follicular stomatitis, and ulcerative stoma- 
titis. The following chapter will be devoted to a serious and often fatal 
disease — gangrene of the mouth, or cancrum oris. 

APHTHOUS STOMATITIS. 

The derangement called aphthous stomatitis (follicular stomatitis or 
aphthae) is a common source of inconvenience to young children. It is 
induced almost invariably by derangement of the stomach, and is often 
seen during the progress of the first dentition — a time at which so many 
forms of gastric and intestinal disorder are apt to arise. Actual irritation 
of the mucous membrane of the mouth may also give rise to aphthae ; for 
children who are over-indulged with sweets often suffer from this com- 
plaint, even if the digestion is unimpaired. 

Symptoms. — Aphthae consists of a vesicular eruption of the mucous 
membrane of the mouth. Pearly gray or yellowish vesicles appear, vary- 
ing in size from a pin's head to a millet-seed. They are circular or oval 
in shape, and their base is surrounded by a red areola. After two or 
three days the vesicle ruptures and a round ulcer remains. The base of 
the ulcer is grayish in colour, from the presence of a sebaceous secretion ; 
the edges are thickened, and there is redness of the mucous membrane 
surrounding the sore. Under appropriate treatment the ulcer soon heals, 
and the complaint is at an end. The number of the aphthae varies from 
two or three to fifteen or twenty, or even more. They may occupy any 
part of the mucous membrane, but usually appear first on the inner side 
of the lower lip and gums ; afterwards on the tip and edges of the tongue, 
the cheeks, and on the palate. 

Aphthae are sometimes accompanied by a considerable rise of the tem- 
perature, and the thermometer may mark 103° or 104° ; but fever is not 



564 DISEASE IN CHILDREN. 

an invariable rule. The tongue is very sore, and the child, if an infant, 
sucks with great difficulty, or may even altogether refuse the bottle or the 
breast. He is peevish and thirsty ; often vomits ; has a sour smell from 
the breath, and shows all the signs of disordered stomach. Often the 
bowels are relaxed. 

If the sores are so numerous as to be almost confluent, the child's con- 
dition may cause some anxiety. He refuses all nourishment on account of 
the smarting excited by the movements of the tongue in the act of swal- 
lowing. His breath is offensive ; salivation is profuse ; the fontanelle be- 
comes deeply depressed, and the sub-maxillary glands are sometimes en- 
larged. This severe form is seldom seen except in weakly babies, and may 
come on at the end of an attack of diarrhoea. In these cases the unfavour- 
able termination of the illness may be hastened by the in^ediment thus 
created to the taking of nourishment. In weakly or cachectic children the 
complaint is sometimes obstinate ; for although the course of each indi- 
vidual ulcer may not be unusually prolonged, fresh vesicles continually 
appear as long as the digestive derangement to which the} 7 owe their origin 
remains unrelieved. Again, in rare cases, the ulcers are slow to heal, and 
may give some trouble before they are cured. 

Diagnosis. — Aphthae are not difficult to recognise. In the vesicular 
stage the nature of the derangement can scarcely be mistaken ; and when 
the ulcers have formed, their circular shape, uniform size, and the limita- 
tion of the inflammation to the immediate neighbourhood of the sore, will 
prevent the disorder being mistaken for the more serious lesion — ulcera- 
tive stomatitis. 

Prognosis. — The derangement is of little consequence, as a rule. Even in 
the cachectic child, in whom the distribution of the sores is more extended, 
and their course more obstinate, than in the healthy subject, any danger 
which may be present is due more to the accompanying general condition 
than to the local complaint. In a healthy subject, the derangement, under 
judicious treatment, will readily subside. 

Treatment. — In ordinary cases of aphthse all that is required is a dose 
of rhubarb and soda, with a grain of gray powder to clear away unhealthy 
secretion from the bowels, and attention to the cleanliness of the mouth. 
After each meal the mouth should be washed out with a piece of linen rag, 
or a large soft brush, soaked in tepid water. Afterwards, glycerine and 
borax (half a drachm to the ounce) may be applied with a soft camel's hair 
pencil. If an ulcer is slow to heal, it may be touched gently with a solu- 
tion of nitrate of silver (ten grains to the ounce of water). 

Tn the more obstinate cases, attention must be paid to the general con- 
dition of the patient, and any chronic derangement of the alimentary canal 
must be remedied. In a cachectic child, the use of an alcoholic stimulant 
in sufficient doses will often cause a speedy improvement in the state of 
the mouth. 

ULCERATIVE STOMATITIS. 

While follicular stomatitis is more common during the first eighteen 
months or two years of life, the ulcerative form of stomatitis is most fre- 
quently seen after the age of two years, when the first dentition has been 
completed. The disease is a common one in hospital out-patient rooms, 
and appears to be predisposed to by insanitary surroundings, a poor die- 
tary, a weakly constitution, or a cachectic state. On this account it may be 
seen in children who are overfed during convalescence from an acute ill- 
ness, and is an occasional consequence of a gastro-intestinal disorder. It 






ULCERATIVE STOMATITIS — SYMPTOMS. 565 

is said, also, sometimes to be epidemic. Its immediate cause is often un- 
cleanliness of the mouth, allowing of the accumulation of tartar on the 
teeth, and sometimes it is set up by the irritation of a decayed tooth. In 
rickety children, and those whose teeth decay rapidly and whose general 
nutrition is unsatisfactory, ulceration of the gums is not an uncommon 
source of discomfort. The influence of feebleness of health, and an in- 
sufficient dietary, in producing the derangement, is so marked as to 
seem to justify Dr. Cheadle's suggestion that many cases of ulcerative ' 
stomatitis occurring in ill-nourished children may be due to undeveloped 
scurvy. 

In addition to the causes which have been mentioned, ulcerative stoma- 
titis may be one of the consequences of a special constitutional disease. 
Thus, it is sometimes present in cases of lymphadenoma, being then due 
to the development of the lymphoid growth in the sub-mucous tissue. 

Symptoms. — The ulceration begins in the gums, and is often confined to 
them. The gums at the affected part become red, swollen, and spongy- 
looking, either generally or in patches. Their edges, especially where they 
rise up between the teeth, are soft, red, and unusually prominent, and they 
bleed very easily. The colour then grows deeper and more purple, and 
often at the borders of the gum the tooth is of a greenish-yellow colour. 
There is some pain in mastication ; salivation is copious, and an offensive 
odour is noticed from the mouth. Soon a soft, pultaceous, grayish-yellow 
matter forms upon the inflamed mucous membrane. This appears to arise 
from gangrenous softening of its most superficial layer, and adheres very 
closely to the tissue beneath it. If detached, an ulcerated surface is dis- 
covered, irregular in shape, grayish in colour, and bounded by a well-defined 
bright red line. If treatment is not promptly resorted to, the disease usu- 
ally spreads from the gums to the tongue, the cheeks, and the lips. On the 
tongue the lesion is usually limited to the part of the organ in contact with 
the affected gum ; and, indeed, in the majority of cases, the ulceration is 
confined to one side of the mouth, and both cheeks are rarely affected at 
the same time. The shape of the ulcerated surface varies according to its 
seat. On the lips it is more or less circular ; on the gums it is elongated, 
and on the interior of the cheek, from conjunction of several neighbouring 
ulcers, it is irregular or sinuous. 

As a consequence of the ulceration of the gums, the corresponding teeth 
often become loose, and sometimes fall out. Chewing is very painful, and 
the child is unwilling, by movement of his jaws, to increase his discomfort. 
Even the motions necessary for swallowing the copious saliva seem to be 
painful, for a young child allows it to flow away from his half -open mouth. 
Like the breath, the salivary secretion is horribly offensive, and is often 
streaked or more or less discoloured with blood. If there is disorder of 
the stomach, the effort of retching may cause a more copious haemorrhage 
from the inflamed and ulcerated surfaces ; and the blood, mixing with the 
vomited matters during their passage through the mouth, may appear to 
come with them from the stomach. 

When the cheek becomes affected there is some swelling, but this is 
moderate, and no induration can be detected. The sub-maxillary glands 
are swollen and sometimes painful. The general health of the child suf- 
fers much less than might be expected. During the first few days the 
temperature may rise to 102°, or even higher ; but the pyrexia quickly 
subsides, and the nutrition of the patient appears to undergo little change 
unless diarrhoea occur. The duration of the complaint is very variable. 
If proper measures are taken, the ulceration is soon at an end ; but if left 



566 DISEASE IN CHILDREN. 

untreated, the lesion may persist for months, and is said sometimes to pass 
into can crura oris. 

Diagnosis. — The general redness of the mucous membrane ; the pulta- 
ceous matter adherent to its surface ; the peculiar fcetor of the breath — 
these symptoms, together with the large size, the irregular shape, and the 
want of uniformity of the ulcers, will serve to distinguish this complaint 
from the preceding. From cancrum oris it is distinguished by its slower 
course, its want of induration, and the absence of black slough. The exu- 
dation cannot be confounded with the leathery, false membrane peculiar to 
the diphtheritic inflammation ; moreover, the latter disease is not usually 
accompanied by ulceration of the mucous membrane. 

Prognosis. — Ulcerative stomatitis is rather inconvenient than dangerous. 
However severe the affection may appear when first seen, it is tractable 
enough when judicious measures are adopted ; and the worst results that 
can follow are loss of teeth, with perhaps a superficial necrosis of an alveo- 
lar process. 

Treatment, — In every case of ulcerative stomatitis our first care should 
be to rectify any deficiencies in the sanitary surroundings of the patient, 
or to remove him at once to a more healthy locality. Fresh air should be 
especially insisted upon, and the child should pass a large part of his time 
out of doors. His diet should be rearranged, giving meat, eggs, and milk 
in suitable quantities, especially avoiding sweets and an undesirable excess 
of farinaceous food. Alcohol is of great value. The child may take port 
wine, diluted with an equal quantity of water, with his dinner, or two or 
three teaspoonfuls of the brandy-and-egg mixture several times in the day 

In addition to the above measures, no time should be lost in prescribing 
chlorate of potash. This remedy has an almost specific action upon this 
form of ulceration. The solution, however, must not be too weak. Three 
grains, dissolved in a teaspoonful of water, may be given every four hours 
to a child of two years old. For an older child, the dose may be increased 
to five or six grains. In some cases, larger quantities are found to be ne- 
cessary, and may be given to quite young children without apprehension. 
A case which has resisted the remedy when given in five-grain doses, may 
yield to it promptly when the dose is raised to fifteen. Of local applica- 
tions, the best is tepid water. Cleanliness is of great importance, and 
after each meal the child, if old enough, should be directed to wash his 
mouth with warm water, so as to prevent food from collecting about the 
inflamed surface. In the case of younger children, the mouth should be 
swabbed out with a piece of soft linen rag dipped in warm water, as 
directed for aphthae. Other applications which may be used are powdered 
alum, or a powder of chloride of lime. These should be applied dry to the 
ulcerated surface with the finger, and are especially useful when the ulcers 
are indolent and slow to heal. Underwood speaks highly of the decoction 
of cinchona, made sharp with dilute sulphuric acid, as an application to the 
sores. Local treatment, however, with the exception of careful cleansing 
of the mouth, is seldom required. Few cases will be found to resist the 
chlorate of potash treatment, especially if this be combined with plenty of 
fresh air, and the employment of an invigorating diet with a sufficient 
quantity of alcoholic stimulant. No local treatment can be expected to 
succeed if .these measures are neglected. 



CHAPTER III. 

GANGRENOUS STOMATITIS. 

Gangrenous stomatitis (cancrum oris, or noma) is fortunately much less 
common than the other inflammatory affections of the mouth and cheeks. 
The disease is a very serious one, and in the large majority of cases proves 
fatal to the child. Even wheu recovery happily occurs, the destruction of 
tissue, if at all extensive, leads to very unsightly contraction of the side of 
the face. 

Causation. — Cancrum oris is seldom seen, except in hospital practice, or 
amongst the poor. It appears to be one of the consequences of a weakly 
habit of body, and is most probably predisposed to by insanitary condi- 
tions and insufficient food. The cases which have come under my notice 
have been in children at the East end of London, living in miserable, 
squalid dwellings, and very poorly clothed and fed. Sometimes the gan- 
grene arises as a sequel of a specific fever or serious inflammatory dis- 
ease. Thus, it has been known to follow measles, typhoid fever, scarlatina, 
and small-pox. It may appear in scrofulous and tubercular subjects, or in 
children who have been exhausted by a prolonged attack of broncho- 
pneumonia, or catarrhal derangement of the bowels. It is doubtful whether 
the injudicious and prolonged use of mercury can set up the disease. That 
it can do so, although stated positively, has been denied with much reason. 
In any case, it is important not to mistake the early symptoms of the dis- 
ease for those of mercurial poisoning. 

Ulcerative stomatitis is said, in rare cases, to end in cancrum oris. The 
two diseases appear to be induced by very similar conditions. A little girl, 
aged five years, died in the East London Children's Hospital from exten- 
sive gangrene of the right side of the face. A few days afterward, her 
brother, aged seven years, was admitted with severe ulcerative stomatitis, 
inside the left cheek/ The parents of these children were very poor, and 
the patients themselves had been half-starved and very insufficiently clad. 
Neither had lately suffered from any acute disease. Cancrum oris is rarely 
seen after the sixth year, and girls are said to be more subject to it than 
boys. 

"Morbid Anatomy.— On post-mortem examination of cases of gangrenous 
stomatitis, the affected part of the cheek or lip is found to be swollen, 
tense, and hard to the touch. It presents, at its most prominent part, a 
dry, black, well-defined slough. This varies in size and shape, according 
to "the extent to which the mortification of the tissues has spread. It may 
clip more or less deeply into the substance of the cheek, and always in- 
volves both surfaces. The tissues in the neighbourhood of the slough are 
thickened, infiltrated, and hardened. Often the dry, black eschar occupies 
the surface of the cheek ; beneath it, the tissues are swollen and indurated, 
and in the interior of the mouth, at the affected part, the mucous mem- 
brane is seen to be occupied by a greyish ulcerated surface, or a moist, 



568 DISEASE IN CHILDKEN. 

loose slough, which can be readily scraped away with the handle of the 
scalpel. 

The gums at the seat of disease are often sloughy and soft ; the teeth 
are loosened, and the alveolar processes blackened and necrosed. Some- 
times the lymphatic glands in the neighbourhood are enlarged. 

According to Rilliet and Barthez, the smaller blood-vessels of the dis- 
eased cheek are obliterated by coagulse where they pass through the mor- 
tified tissues. In parts merely infiltrated and swollen they are still perme- 
able, although their walls are thickened. Batta Segale states that he has 
discovered micrococci and bacilli in the detritus obtained from the gan- 
grenous lesion, but it is not clear that the noma was dependent upon the 
presence of these organisms. 

Other organs may be the seat of disease. Broncho-pneumonia is very 
common, and pysemic abscesses have been found in the lungs. Sometimes 
gangrene of other parts has been seen, especially of the lungs and the 
vulva or scrotum. 

Symptoms. — In some cases pain in one side of the face is the first 
symptom complained of. The child looks pale and ill ; the face begins to 
swell, and at the same time, or soon after, examination of the cheek de- 
tects a firm spot, around which the tissues are soft and cedematous. At 
this stage, inspection of the interior of the mouth will discover a small 
greyish ulcer of the mucous membrane, corresponding to the hardened 
spot felt in the substance of the cheek. The breath has a gangrenous 
odour, and a dark bloody saliva escapes from the mouth. There is little or 
no fever ; the pulse is small and frequent, and the child is unwilling to 
take solid food, probably from the pain excited by mastication. Soon the 
affected cheek becomes tense and shining, the swelling increases, and a 
small red spot forms on the surface. At the same time a brown slough 
developes on the mucous membrane. 

The ulcer is not always seated on the cheek. It may occupy the gum, 
or be placed at the junction of the gum with the cheek, Wherever it first 
appears, it soon spreads, and may involve the gum, the cheek, the lip, and 
perhaps the whole side of the mouth. When the internal slough separates, 
which it may do on the third or fourth day, it leaves a ragged ulcer. At 
the same time, in severe cases, the red spot noted on the outer surface of 
the cheek becomes deeper in colour, and rapidly changes into a dry, black 
slough. Sometimes the internal and external sloughs are separated by in- 
filtrated and cedematous tissue ; but often the two sloughs come into con- 
tact, so as to involve the whole depth of the cheek. In this case, when 
the slough separates, a ragged opening is left, of variable size. In the in- 
terior of the mouth the gums are more or less extensively destroyed ; the 
corresponding teeth get loose, and often fall out, and the maxillary bone 
may become necrosed. The separation of the slough is often unattended 
by haemorrhage, but sometimes copious bleeding takes place. The face, 
on the affected side, where it has not been invaded by the gangrenous pro- 
cess, is swollen and cedematous, and the infiltrated eyelids can no longer 
be opened. 

At this stage the general condition of the child varies. If he have not 
b>een exhausted by previous acute illness, although weak, he is not pros- 
trated, and may be able to sit up in bed without assistance. In most 
cases, however, he is excessively feeble and helpless ; there may be great 
drowsiness ; the pulse is scarcely perceptible ; diarrhoea may come on, and 
general oedema may occur. Sometimes the appetite persists, and the child 
takes liquid food with avidity ; but, usually, towards the end he refuses 



GANGRENOUS STOMATITIS— SYMPTOMS— TREATMENT. 569 

food, and even drink. If broncho-pneumonia supervene, as often happens, 
the temperature, which had been normal, or even below the natural level^ 
rises, and the respiration becomes hurried and laborious. 

In fatal cases the duration of the illness varies according to the rapidity 
with which the gangrenous process spreads, and to the condition of the 
child at the time when the disease begins. In very rapid cases the child 
may die in five or six days. Usually, death takes place between the tenth 
and fourteenth day. If the child be in an enfeebled or cachectic state at 
the time when the first symptoms are noticed, the gangrene usually spreads 
rapidly, and the end may be reached before the slough has had time to 
separate. If broncho-pneumonia arise, or a profuse diarrhoea be set up, or 
septicaemia be induced, or gangrene appear in another part of the body, 
the illness may end in death rather abruptly. 

If recovery take place, it is usually in cases where the gangrene rapidly 
limits itself, and does not spread through the entire substance of the cheek. 
The slough is then thrown off, and a reparative process is set up, which 
ends in more or less puckering of the affected side of the face. The fall of 
the slough is, however, not always followed by repair. In some cases the 
gangrene continues at the borders of the wound, and the morbid process 
goes on unchecked. 

Diagnosis.— Cancrum oris in its mildest form is distinguished from a 
bad case of ulcerative stomatitis by its rapid progress, the induration of the 
cheek at the base of the ulcer, and the infiltration of the tissues around. 
Malignant pustule presents symptoms somewhat similar to those of cancrum 
oris, but differs from it by always beginning on the external surface and 
extending inwards to the mucous membrane. In gangrenous stomatitis, 
the mucous membrane is the first part to be affected. 

Prognosis. — The disease is fatal in the large majority of cases. If it lead 
to perforation of the cheek, especially if the gangrene be widely spread, 
death is almost certain. I have known one case recover after perforation of 
the cheek ; but in this instance, the gangrenous process, although it pene- 
trated deeply into -the cheek, had no great lateral extension. When re- 
covery took place, a deep puckered cicatrix was left in the cheek at the site 
of the disease. 

If a complication arise, such as broncho-pneumonia or diarrhoea, the 
child's small chance of recovery is still further reduced. As long as he con- 
tinues to take nourishment well, and to digest it, we may retain some hope 
of recovery. If he begin to refuse his food, or even to receive it with in- 
difference, the sign is a bad one. 

Treatment. — As in all diseases which result from debility and malnutri- 
tion, measures should be at once adopted to improve the general health, and 
provide the child with suitable nourishment according to his age and diges- 
tive capabilities. Pounded meat, strong beef-tea, eggs, and milk, should be 
given in small quantities at frequent intervals, taking care that the stomach 
is not overloaded, and that the powers of digestion are not overtaxed. 
Stimulants are of great value. Port wine, or the brandy -and-egg mixture, 
should be given several times a day with food. In this disease, a child bears 
stimulants well. Half an ounce of port wine, or two teaspoonf uls of the egg- 
flip, can be given every two, three, or four hours, to a child of five or six 
years of age. The bowels must be attended to, and if much milk is being 
taken, a teaspoonful of compound liquorice powder should be administered 
every other night. Fresh air is also of great importance, and the window 
of the room should be kept open night and day. On account of the foetor 
of the breath, which causes a most offensive odour in the neighbourhood 



570 DISEASE IN CHILDREN. 

of the patient, the room must be frequently sprayed with a solution of car- 
bolic acid (one part in thirty of water). 

For local treatment, our first care should be to destroy the diseased 
surface in the interior of the mouth with a powerful caustic. Strong nitric 
acid is usually employed for this purpose. The acid should be applied once 
and effectually. The operation must be performed with care, so as not to 
touch the teeth, or any part which is not the actual seat of disease ; and 
immediately after the application the mouth should be well syringed with 
a solution of carbonate of soda or chloride of lime. Besides nitric acid, 
strong hydrochloric acid, the acid nitrate of mercury, nitrate of silver, and 
the strong solution of perchloride of iron have been used, and all have 
their advocates. Dr. J. Lewis Smith speaks highly of a combination of sul- 
phate of copper ( 3 ij.) with pulv. cinchona ( § ss.), in four ounces of water. 
This application, which was originally recommended by Maunsell and Evan- 
son, is milder than the others ; but applied carefully twice in the day it is 
said to have remarkable efficacy. If a stronger caustic is employed, a sec- 
ond application should not be made within twenty-four hours of the first ; 
indeed, the operation should only be repeated if the further spread of the 
gangrene is unmistakable. The fcetor of the breath must be corrected by 
frequent syringing with a disinfecting agent. A solution of chlorinated 
soda (liq. sodse chlorinate 3 j., aquae § j.) is perhaps the most useful ; or 
one part of carbolic acid to ten parts of water, as recommended by Labar- 
raque, may be employed for the same purpose. 

The internal administration of quinine and iron seems to be beneficial 
in these cases, given in full doses. A child of three or four years old will 
take well two grains of quinine and twenty drops of perchloride of iron, 
with glycerine and water, every six hours. After separation of the sloughs, 
any sign of repair should be encouraged by stimulating applications. A 
weak solution of sulphate of zinc (gr. iij. to the oz.), or any ordinary lotion 
for granulating wounds, may be used for this purpose. 



CHAPTEE IV. 

THRUSH. 

Thrush is a parasitic disorder, and is due to a fungus which attaches it- 
self to the mucous membrane of the mouth and gullet. The complaint is 
of importance, not so much in itself, for when it appears in a healthy child 
the vegetation is readily dispersed, as on account of the debility and seri- 
ous intestinal and other derangements by which it is often accompanied. 
Strictly speaking, thrush is a symptom rather than a disease, and often in- 
dicates a condition of the system which should give rise to most serious 
apprehension. 

Causation. — Thrush is a cryptogamic growth which finds its nidus in 
altered secretion from the mucous membrane. It is most common in in- 
fants during the first few weeks or months of life, and any derangement 
which involves the mucous lining of the mouth may tend to its production. 
In such subjects, the vegetation is the expression of a local state, and this 
local state may itself be the consequence of a cachectic condition or consti- 
tutional disease. The development of the fungus is favoured by heat of 
weather, want of cleanliness, and indigestible food. It is consequently very 
common during the summer months amongst hand-fed infants, especially 
amongst those who are supplied with a highly fermentable diet, and are al- 
lowed to suck their food from dirty bottles. In such cases, the passage 
through the mouth of sour fluid, and the derangement of the stomach which 
results from fermentation and acidity, maintain a state of constant oral ca- 
tarrh which forms a congenial medium for the development of the parasite. 
In a severe form the complaint is never seen except in imperfectly nour- 
ished infants, whose food is ill-selected, and whose general management 
leaves much to be desired. Imperfect ventilatioD, and general insanitary 
surroundings, are no doubt agencies which further the invasion of the fungus 
and assist its growth. New-born infants crowded together in Foundling 
Hospitals often suffer greatly from such influences, and in these institu- 
tions thrush is a common and much-dreaded visitor. Even after the first 
infancy, the later stage of many acute and chronic forms of disease is liable 
to be complicated by the presence of the parasite, for in the young child 
a catarrhal condition of the alimentary mucous membrane often forms a 
necessary part of such illnesses. 

In children suckled at the breast, the parasite is rarely seen ; and if, on 
account of some temporary derangement, it succeeds in establishing itself 
upon the mucous membrane, it is readily dislodged by suitable treatment, 
and quickly made to disappear. Thrush does not seem to be contagious in 
the ordinary sense of the term. No doubt, if the mycelium be purposely 
brought into contact with the mucous membrane of a child who is in a 
favourable condition for its reception, the plant may flourish in its new 
situation ; but in a child whose mucous membrane is in a healthy state, the 
experiment will be tried in vain. 



572 DISEASE IN CHILDEEN. 

Morbid Anatomy.— The parasitic growth which constitutes thrush, con- 
sists of the mycelium and spores of a cryptogamic vegetation which was 
first described by Robin under the name of oidium albicans. The fungus 
has now been identified by Haller as identical with the cidium lactis which 
results from the acid fermentation of milk. The mucous membrane of the 
mouth is first seen to be red, and its secretion has a distinctly acid reac- 
tion. Then, in the course of a few hours, little white points appear upon 
the reddened surface, especially on the cheeks and the inner surface of the 
lips. These increase in number and in size, and by the second day are 
seen to have united into patches which cover a considerable extent of sur- 
face. Even before the appearance of the white points, a gentle scraping of 
the mucous membrane reveals to the microscope many spores of the fun- 
gus. These are elongated cells — egg-shaped bodies — which are often at- 
tached to one another by their ends, so as to form groups of two, three, or 
four. The white points are found, on examination, to consist of these con- 
nected spores, combined with scaly epithelium from the mucous membrane, 
detached spores and molecular deposit. 

The white, newly-formed membrane coats the interior of the mouth and 
gullet ; but is usually confined to parts covered with scaly epithelium, for 
it avoids the nasal passages, and seldom penetrates into the larynx. Par- 
rot, however, states that he has seen evidence of its presence on the vocal 
cords. The advance of the membrane down the alimentary canal w T as for 
a long time supposed to be arrested at the cardiac end of the stomach ; but 
Parrot asserts that the fungus is occasionally to be discovered in the stom- 
ach and bowels. In these situations it presents a peculiar appearance. 
In the stomach it is seen as small granules, separate or grouped, and vary- 
ing in size from a millet-seed to a particle invisible to the naked eye. The 
smaller are pointed ; the larger are slightly depressed in the middle. In 
colour, they differ little from the mucous membrane on which they are 
placed, but some have a faint yellow tint. They adhere firmly to the sur- 
face, and cannot be scraped off or w T ashed away. The thrush granules affect 
principally the posterior surface, especially the neighbourhood of the pos- 
terior curvature, and he nearer to the cardia than to the pylorus. Sur- 
rounding them, the mucous membrane retains its colour, or is of a rose or 
violet tint. Parrot examined sections of the gastric mucous membrane, 
and found the more superficial portions of the glands to be destroyed by 
the parasitic vegetation, which had penetrated into their interior, and had 
also advanced, although to a less extent, into the intervening tissue. Ac- 
cording to Wagner, the spores and filaments can be sometimes detected 
within the blood-vessels of the part. 

In the intestines, Parrot states that he has succeeded in discovering the 
fungus only in rare cases. In each instance its seat was the caecum. 
Whether the growth has the power of attaching itself to the anus, is not 
clear, for an examination of the whitish pultaceous matter sometimes found 
at the orifice of the rectum, revealed merely pavement epithelium in strati- 
fied layers, with some doubtful cells which presented a certain analogy with 
the filaments of thrush. On the mucous membrane of the mouth, the 
thrush membrane is at first white, and firmly adherent. After a few days 
its colour becomes browner, and its connection with the mucous surface 
less intimate, so that it can be readily wiped away with a brush or piece of 
wet rag. 

In all cases of death from the serious intestinal derangement or the con- 
stitutional cachexia of which thrush is a chief local expression, extreme 
atrophy of the tissues is a striking phenomenon. The infants are usually 



THRUSH — MORBID ANATOMY — SYMPTOMS. 573 

in a state of profound malnutrition, and present, according to Parrot, 
fatty degeneration of the kidneys, the lungs, and the brain, sometimes ul- 
ceration of the stomach, and, not unfrequently, haemorrhages within the 
cranial cavity. 

Symptoms. — In cases where the parasitic growth attaches itself to the 
mucous membrane of a sturdy infant, the appearance of the white points 
is preceded by redness and soreness of the mouth, and a rise of temperature. 
The child is noticed to suck with difficulty, and, if hand-fed, may refuse the 
bottle. He seldom, however, declines the breast for this reason. Often 
he makes movements with his lips, cries if a finger is introduced into his 
mouth, and is evidently uneasy. His temperature often rises at night to 
103° or 104°. At the same time there may be a little looseness of the 
bowels, preceded by colicky pains. The motions are slimy or green, but not 
very offensive. Often they are acrid, and cause some redness and excoria- 
tion of the nates. This is looked upon by nurses as a satisfactory symptom, 
being considered to indicate that the thrush " has gone through " the child. 
In many cases there is derangement of the stomach, and vomiting. 

The above constitutes the whole of the symptoms. Although the tem- 
perature is raised, the stools have an innocent appearance, and the face ex- 
presses no distress. In the mouth, the thrush is limited to a few white 
patches, looking like particles of curd adhering to the mucous membrane. 
They are seen on the inner side of the cheeks and lips, on the tongue, some- 
times on the hard palate, but seldom, in these cases, at the back of the 
throat. They may be removed with a little trouble, and leave the mucous 
surface on which they had been seated raw-looking and bright reel. "When 
thus removed, similar little patches quickly appear in their place, but after 
a few days the surface cleans, and the child is well. 

This simple variety is the shape the complaint assumes in ordinary cases, 
and practitioners whose experience is collected entirely froru families in 
easy circumstances may have observed it in no other form. In hospitals 
and asylums where infants are admitted it is seen as a much more serious 
complaint. In babies who have been neglected or fed injudiciously, and 
confined to dirty, ill-ventilated, foul-smelling rooms — poor, miserable little 
objects, who have sunk from these causes and the consequent bowel derange- 
ment into a state of extreme atrophy and weakness, the whole of the interior 
of the mouth and fauces is often completely lined by the white thrush mem- 
brane. The layer adheres closely to the mucous membrane, and can only 
be detached with great difficulty. If this be done, the mucous surface 
beneath is seen to be raw, and sometimes ulcerated. According to Yalleix, 
shallow ulcers on the hard palate may precede the appearance of the para- 
sitic vegetation. An infant so affected cannot suck, arid, indeed, often can 
hardly swallow. His mouth is dry ; his lips are red and dry-looking, and 
at the surfaces where they come into contact, white scattered particles of 
thrush can be perceived, even when the lips are almost closed. The child's 
eyes and cheeks are sunken ; his face is pale and haggard, and marked with 
a well-defined nasal line which becomes a deep furrow on any movement of 
the lips. The buttocks and genitals are often covered with an erythematous 
or eczematous redness, and ulcerations may be noticed on the internal mal- 
leoli, and sometimes also on other bony projections. His skin is loose and 
is excessively inelastic, often lying in lax folds upon the belly. The child 
whimpers feebly, but never cries. His mouth has a sour, or even a cadaver- 
ous smell. The motions, more or less profuse, are equally offensive. He 
gets weaker and weaker, and gradually sinks out of life. Sometimes the con- 
dition known as " spurious hydrocephalus " is noticed before death. The 



574 DISEASE IN CHILDEEN. 

temperature varies. Sometimes, on the first appearance of the parasite, the 
internal temperature is found to be 101°, or higher, although the extremi- 
ties feel cold ; but after a time the temperature falls below the level of 
health, and may be only 96° or 97° in the rectum. In many of these cases, 
the secretion of urine is diminished. According to Parrot, it often contains 
albumen ; and this pathologist is disposed to attribute the cerebral phe- 
nomena which are apt to occur in these cases to toxic causes, from retention 
in the blood of urinary elements. 

In these severe cases the general symptoms depend upon the intestinal 
catarrh, or other primary lesion, whatever it may be, which has reduced the 
infant's strength, and prepared the way for the invasion of the parasite. 
Often the illness ends in a profuse diarrhoea, but the bowels are not invariably 
relaxed. In some cases, an attack of catarrhal pneumonia, or pulmonary 
catarrh, with collapse of the lung, may bring the life of the infant pre- 
maturely to a close. 

Diagnosis. — Thrush is not difficult to detect. We have merely to ex- 
amine the mouth of the infant, and observe the white adherent patches 
sprinkled over the surface of the mucous membrane. If a particle of one 
of these patches be detached and placed under the microscope, the charac- 
teristic spores and filaments will at once be noticed. 

It is possible that, in the rare cases where diphtheritic false membrane 
is seen on the interior of the lips and mouth, it may be mistaken for thrush, 
but diphtheritic membrane is thicker, tougher, and more leathery in text- 
ure, less white in colour, and under the microscope shows no spores. 
Moreover, the superficial cervical glands are enlarged and tender in diph- 
theria. In cases of thrush they are not affected. 

Particles of curd clinging to the gums and cheeks of a child who has 
just taken his bottle have exactly the appearance of disseminated particles 
of thrush ; but they can be readily wiped off with a small brush or feather, 
and on their disappearance leave no redness of the mucous membrane. 

Prognosis. — In cases of thrush, the probabilities of the child's recovery 
depend partly upon his general condition, partly upon the extent of surface 
covered by the vegetation. If thrush appear in the mouth of a sturdy, 
well-nourished child, as a consequence of some temporary derangement, 
the symptom is one of little consequence, and the parasite can be readily 
dispersed. In 'a child, enfeebled and wasted by chronic digestive de- 
rangement, or the victim of inherited syphilis, the appearance of thrush in 
the mouth is a symptom of the utmost gravity. In such a case, the child's 
only chance of recovery depends upon the rapid introduction of nourish- 
ment into his system, but a deranged condition of the mucous membrane 
may neutralize all our efforts to improve the state of his nutrition. In an 
infant so reduced, the rapidity with which the fungus is seen to spread 
over the surface, may be taken as a measure of the severity of the digestive 
derangement. If it rapidly cover the whole interior of the mouth and 
throat, the child's chances of recovery in his weakly state are small indeed. 

Treatment. — In mild cases of thrush, our first care should be to remedy 
the temporary gastric derangement which has allowed the parasitic growth 
to effect a lodgment on the mucous membrane. The diet must be modified 
as recommended in the chapter on infantile atrophy ; and if the bowels 
are relaxed, the looseness must be arrested by suitable treatment (see 
page 626). If not relaxed, they should be acted on by a dose of rhubarb, 
with a grain of gray powder. Afterwards, a draught containing a few 
grains of carbonate of soda, with an aromatic, should be given three or 
lour times a day. If there is nausea, the stomach should be cleared out by 



THRUSH — TREATMENT. 575 

an emetic of sulphate of copper (half a grain in a teaspoonful of water), or 
a teaspoonful of ipecacuanha wine, given every ten minutes until vomiting 
is produced. 

Fresh air is of extreme importance. If the weather is suitable, the 
child should pass much of the day out of doors ; and especial care should 
be taken that his sleeping-chamber is sufficiently ventilated, and that 
soiled linen is not allowed to remain in the room to vitiate the air.- 

With regard to local treatment : — Perfect cleanliness is indispensable. 
Directly the infant has taken the bottle, his mouth should be swabbed out 
with a piece of soft linen rag, or a large camel' s-hair brush, moistened with 
warm water. Afterwards, the whole of the interior of the mouth should 
be brushed over with a solution of borax (half a drachm to the ounce) in 
water sweetened with glycerine. If this treatment be repeated after each 
meal, it will not be long before all signs of the fungus have disappeared. 

In the more severe examples of the complaint the same local treatment 
must be employed. If the fungus be suspected to have passed into the 
gullet, the child may be forced to swallow a few drops of the wash diluted 
with water. If superficial ulceration are seen, ten grains of sulphate of 
zinc may be added to each ounce of the wash, for use as an application to 
the mucous membrane. The chief difficulty in these cases is to improve 
the child's nutrition and increase his strength. If the parents are in a 
position to supply a wet nurse, this method of feeding should be adopted 
at once. If the child is forced to trust to the bottle, ass' milk or the milk 
of the goat is preferable to that of the cow. Either should be given 
pancreatised according to the method recommended elsewhere (see page 
606). White wine whey is a valuable resource in these cases, and if the 
infant be much reduced in flesh and strength, with small digestive power, 
he may subsist upon it entirely for the first few days. A dessert-spoonful 
of fresh cream shaken up with each bottleful of the whey makes it more 
nutritious, and is a very digestible addition to the meal. In all cases, the 
internal treatment will depend upon the accompanying conditions, and es- 
pecially upon the nature of the illness in the course of which the local com- 
plaint has appeared. Often the child is the subject of a chronic intestinal 
catarrh. This must be treated as directed elsewhere (see page 640). If 
the purging is moderate, and there is no reason to suspect the presence of 
ulceration of the bowels, much benefit may be often derived from a powder 
containing one grain of rhubarb, with one grain of powdered bark, and 
three grains of aromatic chalk, given two or three times in the day. 

Fresh air, with warmth to the belly, and the most perfect cleanliness, 
not only of the child's body and linen, but also of all spoons, cups, feeding- 
bottles, etc., used in his nursery, are essential to his recovery. 



CHAPTER Y. 

PHARYNGITIS. 

Pharyngitis, or sore throat, is common at all ages, and is a frequent com- 
plaint in early life. The disorder may be met with as a simple catarrh of 
mucous membrane ; as an inflammation affecting especially the mucous 
follicles ; as an eruption of herpes in the pharynx, or as part of a severe 
constitutional disease. Four varieties will then be considered, viz., simple 
catarrhal pharyngitis ; follicular pharyngitis ; herpetic pharyngitis, and tu- 
bercular pharyngitis. 

SIMPLE CATARRHAL PHARYNGITIS. 

Causation. — Catarrh of the pharynx, like catarrh attacking other parts 
of the body, is usually the consequence of a chill. Any cause which in- 
clines the body to be affected by changes of temperature will help to induce 
the disorder. It is, therefore, common in scrofulous subjects, in children 
enfeebled by confinement to heated, ill-ventilated rooms, and in those resi- 
dent in houses where the air is contaminated by an imperfect system of 
drainage. Direct irritants to the throat will also set up pharyngitis, which 
at once passes beyond the limits of an ordinary pharyngeal catarrh. The 
children of the poor are often brought to the hospital with severe scalds of 
the throat from attempting to drink boiling water out of the spout of a 
kettle. In the above cases the disorder is a primary lesion. It may, how- 
ever, occur secondarily to some general disease. Thus, catarrh of the 
pharynx is an invariable consequence of measles and scarlatina. It is also 
common in typhoid fever, in rheumatism, and in erysipelas. In all cases, 
the derangement is an acute process, although, if frequently repeated, it 
tends to set up a relaxed and congested state of mucous membrane. 

Symptoms.— In mild cases, the first symptom is usually a sore feeling in 
the throat, which is increased by swallowing. On examination of the 
throat the back of the fauces, the soft palate, and the tonsils are noticed to 
be red, and the latter may be slightly swollen. The tongue is furred, and 
the child is thirsty. In scrofulous subjects the temperature almost invaria- 
bly rises, and there is a certain amount of pallor and languor. In the 
slighter forms little more is to be discovered. After a day or two the child 
begins to snuffle, and the throat affection disappears as a nasal catarrh be- 
comes established. 

In the severe variety the earlier symptoms are more pronounced. The 
child feels ill and looks tired. His face is pale, his eyelids are dark, he 
complains of weariness and aching in the limbs, and asks to go to bed. 
Often he sits over the fire and says he is cold. In a few hours soreness of 
the throat begins. The fauces are found to be red and the tonsils to be 
slightly swollen. Whitish pultaceous matter may be seen at the openings 
of the crypts of the tonsils, and sometimes at the back of the pharynx. In 



CATAERHAL PHARYNGITIS — SYMPTOMS — TREATMENT. 577 

scrofulous subjects the temperature generally rises to 104° or 105°, and in 
such children the glands of the neck, although little enlarged, are tender 
when the neck is pressed. The tongue is thickly furred, and in most cases 
the nasal passages and the gastric mucous membrane are also the seat of 
catarrh. Moreover, the eyes look red and watery, and the child avoids the 
light. In a day or two the catarrh often spreads to the Eustachian tubes, 
so that there is some deafness. The voice is nasal, and swallowing causes 
great pain, so that the child refuses all solid food. The bowels are usually 
confined ; but if there is any intestinal catarrh, the disorder may be accom- 
panied by purging. 

After twenty-four, or, at the latest, forty-eight hours, the fever consider- 
ably diminishes, but the temperature may remain at 100° or 101° for a day 
or two longer. Usually, after the third or fourth day the symptoms begin 
to subside, and by the end of the week the child is convalescent. If the 
patient has suffered many times previously, the deafness may not subside 
with the other symptoms, but may persist for a week or so longer. 

A scald in the throat is accompanied by great nervous prostration. 
There is severe pain in swallowing, and consequently an almost entire ina- 
bility to take food. The mucous membrane of the mouth, palate, and 
pharynx, looks whitish ; raw patches are seen, from which the mucous mem- 
brane has been removed, and there is much swelling. Often the larynx 
is also injured, so that acute laryngitis is set up, and oedema of the glottis 
may be induced. 

Diagnosis.— An ordinary pharyngitis can usually be readily recognised. 
The chief difficulty is to exclude diseases of which pharyngitis is a promi- 
nent symptom, especially scarlatina and measles. 

In scarlatina, the pharynx usually presents a peculiar appearance. The 
redness is of a very bright colour, and is diffused over the whole of the 
fauces. Often it is punctiform on the soft palate, or, even if the redness 
here is uniform, the punctate appearance can be detected at the edges of 
the redness. Moreover, in scarlatina, the feeling of soreness begins quite 
suddenly, as a rule, and the attack is accompanied by vomiting and a very 
rapid pulse. In twenty-four hours the characteristic eruption is to be dis- 
covered. 

If the signs of catarrh are general, and the sore throat is accompanied 
by slight ophthalmia and running from the nose, measles may be suspected. 
Indeed, the invasion of the eruptive fever is accompanied by symptoms 
which cannot be distinguished from those of an ordinary catarrh. If, on 
the third day, the fever is as high, or higher, than on the first, the continu- 
ance of the pyrexia tells in favour of the exanthem ; but no positive opin- 
ion should be hazarded until after the fourth day, when, if the case be one 
of measles, the characteristic rash may be expected to appear. 

Treatment. — It is not often that medical advice is sought in a case of 
ordinary catarrh, the derangement being one which is considered espe- 
cially suitable for domestic medication. If, however, the fever is high, the 
medical practitioner may be called in. A feverish child should be con- 
fined to his bed. He should take a grain of calomel, followed by a saline 
aperient, and his diet should consist of milk, broth, and dry toast. A cold 
compress, or a layer of cotton wool, may be applied to the throat. If the 
case be seen early, it is useful to prescribe the hypophosphite of lime, which 
has' a really remarkable influence in cutting short an ordinary catarrh. 
For a child five years of age, three grains of the salt may be given with five 
drops of spirits of chloroform and ten of tincture of cardamoms, in two 
teaspoonfuls of water, three times a day. A mild catarrh is often arrested at 
37 



578 DISEASE IN CHILDREN. 

once by this means, and even in severe cases the course of the derangement 
is sensibly shortened by the remedy. The pyrexia usually subsides quickly 
after the action of the aperient. If it persist, a drop or two of tincture of 
aconite may be given in a teaspoonful of water every two or three hours. 

If the throat remain relaxed after the subsidence of the pyrexia, a mild 
astringent gargle, if the child can use it, or a rhatany or tannin lozenge 
sucked two or three times a day, will produce a bracing effect. In cases 
where there remains a great sensitiveness to chills, the susceptibility may 
be considerably diminished by the daily use of a cold douche, administered 
in the manner elsewhere recommended (see page 17). 

Severe scalds of the throat usually occur in the younger children. If 
the pain be severe, it may be allayed to some extent by sucking ice, or 
by administering, occasionally, a teaspoonful of crushed ice on which a little 
sugar has been sprinkled. Small doses of opium are often necessary ; 
and this remedy applied locally, as by spraying the throat with glycerine 
and water, made anodyne with a few drops of laudanum, is very beneficial. 
If the child cannot swallow, he may be fed through a stomach-tube passed 
through the nose, as directed in a previous chapter (see page 15). Rectal 
alimentation is very unsatisfactory in young subjects. 

If laryngitis occur, it must be treated as described elsewhere (see 
page 410). 

FOLLICULAR PHARYNGITIS. 

Chronic inflammation of the follicles of the pharynx is an obstinate com- 
plaint which is' often seen in children. The disorder is an important one, 
as it may induce deafness, and frequently gives rise to a persistent cough, 
which is a cause of much anxiety to the patient's relatives. 

Causation. — Follicular pharyngitis is especially likely to attack strumous 
subjects, and those who belong to families in which there is a gouty or 
rheumatic tendency. The disorder is not often seen in very young chil- 
dren, although Dr. Morell Mackenzie has met with it as early as the third 
year. It is most commonly found in children of eleven or twelve years of 
age and upwards. It sometimes appears to follow certain specific fevers, 
such as measles, scarlatina, and small-pox. In other cases it is apparently 
excited by exposure to cold acting upon a weakly frame. The subjects of 
the disorder are often ill-nourished and feeble-looking ; and this fact, 
coupled with the cough which is so common a consequence of the disease, 
may give rise to fears of consumption. 

Morbid Anatomy. — The follicles are enlarged and their walls thickened. 
They are filled with a cheesy secretion consisting of degenerated epithelial 
cells, molecules, and oil-globules ; and sometimes contain concretions of 
carbonate of lime. 

Symptoms. — The case is seldom seen until the derangement is advanced. 
It is then, usually, as has been said, the cough which excites the alarm of 
the parents. The cough is frequent and hard, and the child often clears 
his voice, and when questioned complains that he has a " tickling " in his 
throat. The symptoms vary in severity from time to time. When the dis- 
ease is severe, the cough is accompanied by pain shooting up into the 
head or ears. It often comes on in paroxysms, and these are apt to occur in 
the night. There is also an uneasy sensation in swallowing, and the child 
may complain that " coughing makes his throat sore." In advanced cases 
the disease extends to the larynx, producing hoarseness, and into the Eus- 
tachian tubes, causing dulness of hearing. If the posterior nares are at- 
tacked, the sense of smell may be impaired ; if the soft palate, the sense 






FOLLICULAR PHARYNGITIS— SYMPTOMS — TREATMENT. 579 

of taste may be affected. Loss of these senses is not common in the child, or 
is difficult to ascertain ; but a certain impairment of hearing is frequently 
complained of. Indeed, I am informed by Mr. Beeves that of the children 
who are brought on account of deafness to the Ear Department of the 
London Hospital, a full third owe their infirmity to this affection of the 
throat. In such cases, a peculiar flattening of the nostrils is often pro- 
duced, owing to the swelling of the posterior nares. The appearance is 
similar to that which has been so often remarked upon as resulting from 
a chronic enlargement of the tonsils, and is indeed produced, like it, by 
the disuse of the nasal passages in respiration. Disease of the middle ear, 
with discharge from the meatus, may be also a consequence of the pharyn- 
geal affection. A catarrh is very apt to spread along the Eustachian tube 
into the tympanum ; and the secretion being unable to escape through the 
occluded tubes, accumulates, and leads to ulceration of the tympanic mem- 
brane, and otorrhoea. 

In mild cases of follicular pharyngitis there is little interference with 
deglutition ; but when the disease is more pronounced, swallowing may be 
difficult as well as painful, and the attempt to swallow is said sometimes 
to give rise to spasm of the pharynx. 

On inspection of the fauces, we find small eminences scattered over the 
mucous membrane at the back of the pharynx. These are rounded or 
elongated in shape, and may be so numerous as to present a granular ap- 
pearance. Their colour, and that of the whole mucous membrane, is deejDer 
than natural, and enlarged superficial veins may be seen running in the 
depressions between the prominent follicles. If the disease is extensive, 
similar granules are found on the pillars of the fauces and on the tonsils. 
Sometimes mucus, more or less stringy and turbid, may be seen clinging 
to the tonsils, or hanging down from behind the soft palate, and this may 
be mixed up with yellow-looking exudation from the diseased follicles. 

In scrofulous children, ulceration is very apt to occur. The ulcers are 
seated in the follicles. If isolated, they are small and circular, but when 
placed closely together, they are larger and irregular from junction of the 
borders of neighbouring sores. The uvula is elongated, and its surface is 
dotted over with enlarged glands. 

Diagnosis. — The diagnosis of follicular pharyngitis presents no diffi- 
culty. If the patient is brought on account of cough, examination of the 
chest usually reveals no sign of disease, while inspection of the throat dis- 
covers the characteristic granular appearance of the pharynx. 

Prognosis. — In children, the disease can usually be arrested by suitable 
treatment, but it may tend to recur afterwards from slight exposure. 
Follicular pharyngitis may be associated with phthisis, and, according to 
Dr. Horace Green, is sometimes a cause of it. 

Treatment. — As children suffering from this complaint are usually 
weakly and under-nourished, the general health must be first attended to, 
and the child will often be greatly benefited by cod-liver oil and tonics, 
such as iron and quinine. A little sound claret diluted with water may be 
given him with his dinner. In fact, the constitutional treatment recom- 
mended in cases of strongly marked strumous diathesis is often required. 

For a cure of the local "disorder, local treatment is essential. In mild 
cases, a more healthy action of the pharyngeal mucous membrane ma;, 
induced by astringent applications, especially by brushing the throat two 
or three times daily with the glycerine of tannin, or with equal parts of 
strong perchloride of iron and glycerine. Dr. J. Sawyer speaks highly of 
the local application of borax. A saturated solution should be sprayed into 



580 DISEASE IN CHILDREN. 

the throat for several minutes, three or four times in the day, at an interval 
after food. The extract of eucalyptus, in the form of a lozenge, is also 
serviceable when secretion is copious. 

In more severe cases, it may be necessary to destroy each follicle sep- 
arately by a caustic or the galvanic cautery. The latter, which can be put 
cold into the throat and rapidly heated in situ, is no doubt the most con- 
venient. Moreover, its action being instantaneous, the application is less 
painful than that of the more slowly-acting escharotic. If a caustic be used, 
nitrate of silver, properly employed, is one of the most successful. The 
throat must be first cleansed with a brush soaked in warm water ; then 
with a piece of lunar caustic, sharpened to a fine point, each enlarged follicle 
or ulcer must be touched separately. The number of follicles to be de- 
stroyed at one visit must vary according to the sensitiveness of the child, 
and the distress produced by the application. On the first occasion, only 
one or two may be destroyed as a trial test. 

Instead of the lunar caustic, other caustics, such as Dr. Morell Macken- 
zie's "London paste," may be employed. 

HERPES OF THE PHARYNX. 

Herpes on the skin is a common eruption in the child. Sometimes the 
rash appears on the pharynx, and produces great discomfort. 

Causation. — The causes of herpes are doubtful. The complaint is said 
to be excited by exposure to cold, but a constitutional tendency appears to 
be necessary to its development. There is no doubt that, as Trousseau 
first pointed out, pharyngeal herpes is especially common during outbreaks 
of diphtheria, and that in such cases the zymotic disease may become en- 
grafted upon the herpetic eruption. 

Symptoms. — The complaint begins with febrile symptoms, followed 
after a few hours by soreness of the throat. The child complains of a 
painful feeling in deglutition, which is usually distinctly confined to one 
spot. On examination, a few whitish vesicles are seen clustered together 
on the soft palate, on one of the pillars of the fauces, or on one of the 
tonsils. Around them, the mucous membrane is redder than natural, and 
swollen. Sometimes the vesicles are more numerous, and more generally 
distributed. The vesicles last from twenty-four to forty-eight hours, and 
may then disappear without rupture, or burst, leaving little white spots 
from macerated epithelium, or circular ulcers which soon heal. Some- 
times, instead of healing rapidly, the ulcers become covered with pulta- 
ceous exudation, and, if the sores are numerous, the exudation may form a 
continuous layer. More usually, however, the patches are small and iso- 
lated. Their seat is generally the soft palate, or one tonsil ; seldom the 
back of the pharynx. After three or four days the exudation becomes de- 
tached and disappears. Sometimes more than one crop of vesicles is no- 
ticed. Often, herpes of the pharynx is associated with the same condition 
of the lip ; and the vesicles are said sometimes to invade the larynx and 
the openings of the Eustachian tubes, so as to affect the respiration and 
the sense of hearing. 

Diagnosis. — "When the disease is seen in the vesicular stage it is readily 
recognised. If, however, inspection is delayed until the patches of exuda- 
tion have formed, the case may be mistaken for one of diphtheria ; more 
especially, as this form of the complaint is often associated with outbreaks 
of that disease. If, however, herpes of the lip is present, and especially if 
small circular ulcers can be seen mixed up with the small patches of exu- 



HERPES OF THE PHARYNX — TUBERCULAR PHARYNGITIS. 581 

dation, we may suspect pharyngeal herpes. Still, it is often impossible to 
distinguish the case from a mild attack of diphtheria. 

Treatment. — The complaint requires little treatment. Attention must 
be paid to the bowels. If the tongue is furred, it is well to administer a 
mercurial purge, such as a grain of calomel with two or three grains of 
jalapine. While the pyrexia lasts, the child should be kept in bed and put 
upon slops — indeed, the pain induced by deglutition will prevent his wish- 
ing to swallow solid food. If the fever is high, tincture of aconite may be 
given in doses of one or two drops, every hour, or two hours. If the dis- 
comfort in the throat is great, it may be relieved by inhalations of steam, 
medicated with compound tincture of benzoin ( 3 j. to the pint). If in the 
stage of exudation there is any foetor of the breath, inhalations or sprays 
containing creasote or carbolic acid (V\ xx. of each to the pint) may be 
made use of. As an internal remedy for children, Dr. Morell Mackenzie 
speaks highly of arsenic. Three or four drops of Fowler's solution may 
be given three times a day, directly after food, to a child five years of age. 
If there is any doubt as to the nature of the complaint, and diphtheria be 
epidemic in the neighbourhood, the treatment for that disease should be 
at once adopted. 

TUBERCULAR PHARYNGITIS. 

In children, the subjects of tuberculosis, the pharynx, like any other part 
of the body, may become affected as a consequence of the diathetic state. 
The pharyngeal complaint is only a part of the general disease ; but it may 
occur in children in whom no pulmonary symptoms are present, and in 
subjects who have not previously suffered from delicacy of the throat. 

Morbid Anatomy. — The mucous membrane is the seat of ulceration, 
which is limited at first to one side of the fauces. The ulcers are due to 
the caseation and breaking down of gray granulations themselves, and not 
to the development of these granules around a sore formed by the disin- 
tegration of ordinary cheesy matter, such as may result from proliferation 
of the cellular contents of a glandular follicle. Friinkel states that in a 
previously sound portion of the velum palati he has been able to follow the 
whole process with the eye. Thus the gray nodules have sprung up, have 
become caseous and disintegrated, and have been replaced by ulcers under 
his own immediate observation. On microscopic examination, the base of 
the ulcer is seen to be infiltrated with round cells, which permeate the 
sub-mucous tissue, and even reach to the muscles. The same cells also 
infiltrate the cellular tissue of the glandulse. The special gland cells are 
often in a state of fatty degeneration, and tend to become cheesy. 
• The other organs of the body are also the seat of the gray granulation. 

Symptoms. — The first symptom pointing to the throat is soreness, and 
this seems to be exceptionally severe, for the child makes it the subject of 
continual complaint. In deglutition the pain often shoots up to the ears, 
and usually becomes so great on taking solids that no persuasions can in- 
duce the child to swallow anything but liquid food. In addition to pain, 
there is sometimes difficulty in deglutition, and liquids may return through 
the mouth and nose. 

On examination of the throat, the mucous membrane is seen to be ul- 
cerated. The ulcers generally begin on one side— on the tonsil or one of 
the pillars of the fauces, and spread slowly to the soft and hard palate and 
the back of the pharynx. According to Frankel, they begin as gray isolated 
or confluent nodules, which afterwards undergo caseous degeneration and 
ulceration. They tend to spread transversely rather than in a vertical di- 



582 DISEASE m CHILDREN. 

rection, and seldom penetrate deeply into the tissues. The floor of the 
ulcer is irregular and cheesy ; the borders are congested and undermined. 
In the neighbourhood of the sores, gray miliary nodules can be distinctly 
seen dotting the mucous membrane. If the uvula is not invaded by the 
destructive process, it often becomes atrophied. In the opposite case, it 
swells to a considerable thickness, and may be dotted over with hard nod- 
ules. Eventually it may be eaten away. 

The ulceration may spread extensively. In a case reported by Dr. Gee 
— a child six years old — the whole of the pharynx down to its union with' 
the gullet was covered with yellow purulent matter. The mucous mem- 
brane was extensively destroyed, so as to lay bare the pharyngeal muscles. 
The soft palate, back and front, was in the same condition. The uvula was 
destroyed, as well as the mucous membrane of the tongue, half way to the 
foramen caecum. The right tonsil was gone, and the ary-epiglottidean 
folds were ulcerated superficially. The true vocal cords and the larynx 
below them were unaffected. 

As a consequence of the ulceration, the voice acquires a nasal quality, 
as it does in most cases of pharyngitis. The glands of the neck become 
enlarged along the borders of the sterno-mastoid muscles, and at the angles 
of the jaw. 

When the case is first seen, the general nutrition of the child is not 
necessarily unsatisfactory. The degree to which it is impaired depends in 
a great measure upon the period at which the pharyngeal affection arises 
in the general disease. If it occur early, the child, although thin, is not 
emaciated. His thinness is no doubt chiefly due to the influence of the 
cachexia upon nutrition, but is probably also in part the consequence of dif- 
ficulty and pain in swallowing, w r hich is a bar to the taking of sufficient food. 
The general symptoms are those of tuberculosis. There is fever, but sel- 
dom a very high temperature, the evening rise not often passing beyond 
102° or 103°. There is usually cough, and an examination of the chest 
may detect signs of consolidation ; but in some cases no evidence of tuber- 
cle can be discovered at first in either the chest or the abdomen. As the 
disease advances, however, signs of mischief become manifest in other parts 
of the body. Spots of dulness may be discovered at the apices of the 
lungs ; a secondary catarrhal pneumonia becomes developed ; signs of 
tubercular peritonitis are to be discerned, or symptoms of tubercular men- 
ingitis occur ; and sometimes a persistent purging is set up, with all the 
signs of tubercular ulceration of the intestines. 

Diagnosis. — The chief difficulty in the diagnosis of tubercle of the 
pharynx lies in separating it from syphilitic ulceration of the same part. 
The distinction is, however, easier in the child than it is in the adult, for 
in young subjects the latter disease is almost invariably a congenital mal- 
ady. If, then, by careful questioning of the parents, we can find no history 
of miscarriages on the part of the mother, or of syphilitic symptoms in the 
patient himself shortly after birth ; if the child bear about him no evi'dence 
of past syphilitic disease, such as flattened bridge of the nose, small pits, 
and linear cicatrices about the angles of the mouth, prominence of the fore- 
head, opacity of the cornea, or enlargement of the spleen ; if, too, the per- 
manent incisors have appeared and show no sign of malformation — in such 
a case we may exclude syphilis with tolerable certainty. If, on the other 
hand, a hereditary tendency to phthisis can be discovered, or if other chil- 
dren of the family have died with symptoms of tubercular meningitis, the 
evidence is in favour of tubercle. Still, a history of syphilis, although point- 
ing strongly to this cause for the ulceration, does not make it certain that 



TUBERCULAR PHARYNGITIS— DIAGNOSIS— TREATMENT. 583 

the pharyngeal disease is a result of the venereal taint, for a syphilitic child 
may fall a victim to tuberculosis. Nor, again, if signs of tubercle are to be 
discovered in other organs, can we, from this circumstance alone, positively 
exclude a syphilitic origin of the throat lesion, unless we are supported in 
this judgment by the family and personal history of the child. Fortunately, 
however, careful observations of the fauces itself furnishes sufficient evi- 
dence. In syphilis, the ulcers have sharper edges, penetrate more deeply, 
tend to produce contractile scars, and have no gray nodules in their neigh- 
bourhood. Tuberculous ulcers, as has been already remarked, are super- 
ficial, as a rule, with irregular nodular, eroded, and undermined edges, 
and a cheesy floor. In their neighbourhood, gray miliary nodules are 
seen underneath the epithelium. Moreover, in tuberculosis, the ulceration 
spreads very slowly, and the cervical glands are invariably enlarged. In 
syphilis, the extension is more rapid, and the glands of the neck are rarely 
indurated and swollen. Again, syphilitic ulceration is not accompanied by 
fever, while in tubercular pharyngitis the temperature is always elevated. 
The diagnosis will therefore rest upon the complete absence of all syphilitic 
history, either family or personal ; the appearance of the sores themselves, 
with the gray miliary nodules in their neighbourhood ; the enlargement 
of the superficial glands, and the presence of fever. 

Prognosis. — The disease is always fatal ; and, indeed, the pharyngeal 
lesion tends to hasten the end by the rapid exhaustion it induces through 
the difficulty of supplying a sufficient quantity of nourishment. Death 
usually occurs in from two to six months. 

Treatment. —Little can be done in the way of treatment in retarding 
the downward course of the illness. Nutritious food in small bulk, such 
as meat essence, pounded meat made liquid with gravy, yolks of egg, milk, 
etc., should be given ; and the strength of the patient may be also sup- 
ported by doses of the brandy-and-egg mixture or port wine. If the child 
be unwilling or unable to swallow, nourishment must be administered by 
the stomach-tube passed through the nose. 

We must endeavour to relieve the distress of the child by soothing ap- 
plications. Brushing the affected part with glycerole of morphia is recom- 
mended by Isambert. For a child of seven or eight years old, the strength 
of the application may be one grain in three drachms. Inhalations of 
steam also appear to relieve. 



CHAPTER VI. 

QUINSY. 

Acute inflammation of the tonsils, or quinsy, is a frequent complaint of 
later childhood, but is comparatively rarely met with during the first few 
years of life. One of the peculiarities of the affection is its disposition to 
recur. A first attack leaves behind it a tendency to a second, and the 
same subject will be found to suffer from the disease again and again under 
the influence of apparently trivial causes. A common consequence of 
these repeated attacks is a hypertrophied condition of the tonsils. This 
may be a source of great inconvenience, and may even have a serious ef- 
fect upon the health and general development of the child. 

The tonsils are often found to share in a general inflammation affecting 
the mucous membrane of the mouth and fauces, and in scarlatina and 
diphtheria they are almost invariably inflamed and swollen. The name 
" quinsy " is, however, applied to a special primary affection which appears 
to be something more than a mere local complaint. Acute tonsillitis has, 
indeed, been compared to croupous pneumonia — another disease which is 
no longer regarded as a purely local inflammation. ]n each of these forms 
of illness, we find general symptoms severe out of all proportion to the 
local lesion ; a rapid rise of temperature which often precedes the more 
special symptoms, and a critical fall on the fifth or sixth day. In each dis- 
ease, too, the attack appears to be due to very similar causes. 

Causation. — Although occasionally met with in young children, quinsy 
cannot be said to be common until about the eighth or ninth years. In all 
cases there is probably a special individual susceptibility rendering the 
patient more liable to be affected by cold and damp, which appear to be 
the ordinary causes of catarrh. Any influence which exercises a depressing 
effect upon the system will no doubt assist the action of these causes, and 
some observers are disposed to believe that in unfavourable subjects such 
depressing influences alone are capable of exciting the attack. There ap- 
pears to be a distinct connection between tonsillitis and acute rheumatism. 
Quinsy is common in rheumatic subjects, and attacks of rheumatism are 
often preceded by acute inflammation of the tonsils. Indeed, so frequently 
is this the case that quinsy has been looked upon as an early manifestation 
of the rheumatic tendency. 

The inhalation of sewer gas is another common cause of tonsillitis. 
Inmates of houses where the waste-water pipes run directly into the soil- 
pipe, or where the main soil-pipe is defective and leaks under the basement 
floor, are often subject to repeated attacks of quinsy, and also to a slower 
inflammation of the tonsils, which resists all treatment as long as the pa- 
tient remains in the vitiated atmosphere. 

Chronic hypertrophy of the tonsils is not always the consequence of 
the acute form of the disease. In scrofulous children, enlargement of these 
glands may arise from a process of slow inflammation. The same thing is 



QUINSY— CAUSATION — MORBID ANATOMY— SYMPTOMS. 585 

occasionally seen in children in whom no hereditary diathetic tendency can 
be discovered, and in families where the other members are strong and 
healthy. In these cases it will be generally found that the patient, if he 
has not suffered from repeated attacks of the acute form of the disease, 
has been long exposed to insanitary or other depressing influences by which 
his development and general nutrition have sustained distinct injury. 
The child may have lived in a vitiated atmosphere, been overworked at 
school, or been subjected to other sources of depression which have reduced 
his strength and diminished his vital powers. 

The chronic inflammation of the tonsils, which is the consequence of a 
diathetic tendency, is seldom seen before the fifth or sixth year. When the 
hypertrophy occurs in children of healthier constitution, it often begins 
earlier, being found in infants under twelve or eighteen months old. It 
has been suggested by Robert, that in such young subjects the enlargement 
may be a consequence of teething, and it is possible that the change in the 
tonsils may have some connection with the general glandular activity which 
is known to prevail at this period of life. 

Morbid Anatomy. — In acute tonsillitis, the inflamed tonsil becomes swol- 
len with inflammatory exudation. An increased production of epithelial 
cells takes place in the recesses of the gland. The crypts are distended 
with them, and the cells appear as creamy-looking masses at the orifices. 
Almost at the same time the lymphatic follicles swell and soften, and form 
abscesses which run together so as to give rise to a considerable collection 
of pus. This is eventually expelled by one or more openings. The inflam- 
mation then subsides, and the swelling more or less completely disappears. 
It seldom happens that both tonsils are attacked at exactly the same time. 
Usually, the inflammation begins first on one side, and partly runs its course 
before the tonsil on the other side begins to suffer. There is also more or 
less inflammation of the soft palate and pillars of the fauces, and the salivary 
glands may participate in the inflammation and get hard and swollen. 

In tonsils permanently enlarged from chronic inflammation, the increase 
in size is due to an inflammatory hypertrophy of the sub-mucous connec- 
tive tissue. The glands are enlarged and hard, and their surface is often 
Uneven. 

Symptoms. — The inflammation begins with a chill, or even a distinct 
rigor, and the child complains of a feeling of dryness and aching in the 
region of the fauces. His temperature rises to between 102° and 103°, 
and he looks and feels ill. Often there is general aching and soreness of 
the body, such as is experienced at the beginning of attacks of severe 
catarrh ; the pulse is rapid and full, and the tongue is thickly-coated with 
fur. On inspection of the throat, the tonsils are seen to be swollen and 
vividly red, and there is also redness of the soft palate, uvula, and pillars 
of the fauces. The uvula is not, however, swollen at the first, although 
later it is apt to become cedematous. 

As the inflammatory process increases, the pain and aching at the back 
of the throat grow more distressing, and the discomfort is increased by a 
secretion of thick mucus from the inflamed mucous membrane. Degluti- 
tion is accompanied by a sharp pain, which often shoots up into the ears 
and side of the head, and all movement of the jaws is painful. The child 
is afraid or unable to swallow, and often an attempt to do so produces a 
choking sensation, and a return of the fluid through the nose. Singing in 
the ears and deafness are often present, and the voice of the sufferer has a 
peculiar nasal quality which is very characteristic. At the height of the 
disease, the temperature is often as high as 104° ; the skin is moist and 



586 DISEASE IN CHILDREN. 

clammy ; the pulse is rapid and compressible ; there is a feeling of great 
prostration, and the face is pale, haggard, and distressed. 

If one tonsil only be affected, at the end of five or six days a yellowish 
spot can be detected on the reddened and glossy surface of the gland. In 
a few hours, or on the following day, the abscess bursts at this point, and 
discharges a large quantity of thick pus, to the great and almost immediate 
relief of the patient. Often, however, at this time, or shortly before, the 
opposite tonsil begins to swell, and the discomfort, if it had partially abated, 
returns. 

The swollen gland may reach a large size. It can be felt externally 
behind the angle of the jaw, and often seems to block up the whole pas- 
sage of the throat. When the inflammation runs its course on both sides 
at the same time, there may be difficulty of breathing, and the face assumes 
an agonized expression of distress. Fortunately, any but a favourable ter- 
mination to the complaint is excessively rare ; and the child's friends may 
be comforted b} T the assurance that the severity of the symptoms is out of 
all proportion to the actual danger of the illness, and that recovery may be 
expected with confidence. When the abscess bursts, its purulent contents 
are almost invariably swallowed by the child ; but the cessation of much of 
his distress, the relief shown in his face, the rapid fall of temperature, and 
the improvement in his general symptoms, allow us to infer, even with- 
out examination of the throat, that evacuation of the matter has occurred. 

After discharge of its contents the gland begins to diminish in size ; 
deglutition, although still painful, is accomplished with greater ease ; the 
haggard expression of the face disappears, and the desire for food begins 
to return. Often, at this time, a discharge of blood takes place from the 
abscess. The appearance of blood from the mouth maybe a cause of great 
alarm to the child's relatives, and it is well to warn them of the possibility 
of its occurrence. 

The duration of the disease is from one to two weeks, according to 
whether both tonsils or only one becomes inflamed. Convalescence is 
short, and after the cessation of the attack, the child quickly recovers his 
strength. 

In a considerable proportion of cases, especially if judicious treatment 
is early adopted, the inflammatory process stops short of suppuration. The 
redness then begins to diminish, and the swelling to subside, at the end of 
forty-eight hours, or in the course of the fourth day. In many of these 
instances, the red and swollen tonsils are speckled over with gray patches 
from the secretion at the mouths of the follicles, and sometimes shallow 
ulcers are seen on the inside of the cheeks and lips, or on the tongue, but 
rarely on the tonsils themselves. In this form of the disease, the febrile 
action is less high than in the suppurative variety, but the depression and 
feeling of illness are fully as severe. When occurring in this form, tonsil- 
litis is probably always a consequence of insanitary conditions. The cases 
are often met with in groups, several inmates of the same house or row of 
houses being attacked almost at the same time. Although included under 
the name of quinsy, the disease is probably distinct in its nature from the 
suppurative variety, and, if suitable treatment be adopted early, it can be 
readily arrested. 

In chronic hypertrophy of the tonsils, the glands are enlarged and hard. 
They can be felt externally behind the angle of the jaw, and, on inspection 
of the throat, are seen as two globular bodies projecting towards one an- 
other, so as almost to touch in the middle of the throat. The anterior sur- 
face is smooth and shining, but the internal face is irregular from the open- 



QUINSY— SYMPTOMS. 587 

ings of the glandular recesses. Their colour is usually of a pale brick red, 
but when at all congested, as they are apt to be on the occurrence of the 
slightest|chill, they become of a deeper tint, and yellow curdy masses appear 
at the orifices of the crypts. At these times, they often meet in the middle 
line, and the friction of the two bodies against one another may, as Dr. 
G. V. Poore has pointed out, be a cause of superficial ulceration. One of 
the results of this chronic enlargement of the glands is the frequent recur- 
rence of attacks of inflammation, which, although amounting to no more 
than superficial pharyngitis, are yet a source of great discomfort. Usually, 
at least once in the twelve months, the inflammatory process is more severe, 
and the patient passes through a regular attack of quinsy. 

A child who suffers from this chronic enlargement of the tonsils, presents 
many very characteristic symptoms. He has often an unhealthy appearance, 
being undersized, pale, and thin. The imperfect state of nutrition in such 
patients is well seen in cases where one member of a family is alone af- 
fected. The frail appearance of the child then contrasts strikingly with 
the robust and healthy look of his more fortunate brothers and sisters. It 
has been supposed that this imperfect performance of the nutritive pro- 
cesses is due to the impediment to respiration set up by the swollen bodies, 
and the consequent insufficient combustion of waste-products in the body. 
I cannot, however, think this a satisfactory explanation of the phenomenon. 
It appears to me to be rather the result of the striking susceptibility to 
chills almost invariably manifested by these patients. Their gastric mu- 
cous membrane is therefore kept in a state of almost continual catarrh. As 
a consequence, digestion is laboured and imperfect, and the nutritive needs 
of the system are insufficiently supplied. Such children are often exces- 
sively irritable and restless. Their complexion is sallow, with a dark dis- 
colouration under the eyes. They sleep badly at night, dreaming and talk- 
ing incoherently. Their bowels are often confined, and their stools light- 
coloured and offensive. Sometimes the face turns suddenly white, and 
the child complains of flatulent pains and of distention of the belly. 

In all cases where the enlargement of the glands is at all considerable, 
the mucous membrane in the neighbourhood of the tonsils is habitually 
congested and relaxed. The child snores in his sleep ; speaks with a thick 
nasal tone of voice, and may be dull of hearing from the turgid state of 
his Eustachian tubes. Slight haemorrhages often occur at night from the 
surface of the glands, and blood-stained saliva may flow from the child's 
open mouth on to the pillow. Sometimes the posterior nares are almost 
completely closed to the passage of air. The nostrils then become 
flattened so as to narrow the nasal apertures. In such children, the palate 
is often high and arched ; the upper jaw is small ; the teeth are crowded 
and overlap, and the front of the jaw is curiously rounded at the lips. 

In extreme cases, the entrance of air through the larynx is impeded ; 
often sufficiently so to induce a state of permanent collapse at the bases of 
the lungs. The lower end of the sternum, with the cartilages connected with 
it, is then forced backwards so as to present a cup-shaped depression at 
that point. The upper portion of the sternum is made prominent, and one 
form of pigeon-breast is produced. This variety of the pigeon-breast may 
be readily distinguished from a somewhat similar condition in the rickety 
child. In the latter, the whole sternum protrudes, from softening of the 
ribs. In the former, the upper part of the breast-bone is prominent, and 
the depression at the lower part is the result of yielding, not in the ribs, 
but in the cartilages. 

Fcetor of the breath is a common consequence of enlarged tonsils, for 



588 DISEASE IN CHILDREN". 

the glandular recesses become filled with a cheesy, decomposing secretion. 
Cough is also a frequent symptom It is often distressing and paroxysmal, 
and when combined with the pallid, weakly appearance above referred to, 
may give rise to fears of consumption. Such apprehensions are sometimes 
rather confirmed than allayed by the results of a physical examination of 
the chest. In many such cases, a peculiar hollow quality of breath-sound, 
probably conducted from the pharynx, is heard with the stethoscope at each 
supra-spinous fossa. To an inexperienced observer, this sign may sug- 
gest consolidation of the lungs. There is, however, no dulness on percus- 
sion, and the abnormal quality of breath-sound is heard principally in ex- 
piration, and is greatly diminished, or even completely suppressed, when 
the child opens his mouth widely. 

Diagnosis. — Primary inflammation of the tonsils can only be mistaken 
for the secondary inflammation which occurs in scarlatina and diphtheria. 
In the first case, the absence of the characteristic eruption at the end of 
twenty-four hours is quite sufficient to exclude the infectious fever. But, 
besides the rash, the appearance of the inflamed mucous membrane is very 
different in the two diseases. In scarlatina, it is more widely diffused, and 
of a more brilliant red, than at the beginning of quinsy ; and on the soft 
palate the redness is usually punctiform, which is not the case in tonsillitis. 

In diphtheria, the ash-coloured leathery appearance of the false mem- 
brane is different from the curdy patches of quinsy ; and in the former 
disease there is early swelling of the cervical glands. In inflammation of 
the tonsils these glands are not usually affected. 

Prognosis. — In quinsy, the prognosis is rarely otherwise than favourable. 
Cases are said occasionally to have happened in which suffocation has re- 
sulted from the inflammation. Eilliet and Barthez have referred to such a 
case, in which a little girl, aged thirteen, died of suffocation on the second 
day ; but it is very doubtful if this was an uncomplicated case of quinsy, 
and the accident is one .not greatly to be dreaded. 

In cases of chronic enlargement of the tonsils, the glands, if left alone, 
usually become smaller after puberty. But while they remain swollen they 
give rise to so much inconvenience as well as induce so much interference 
with the nutritive processes, that measures should be always adopted for 
their early reduction or removal. 

Treatment. — In every case of quinsy it is advisable, as an important 
preliminary to further treatment, to clear out the bowels with a good mer- 
curial purge, followed by a saline draught. Linseed-meal poultices, or a 
cold water compress, must be kept applied to the throat, and if old enough 
to gargle, the child may use a weak solution of chlorate of potash sweetened 
with glycerine. If the case is seen early, aconite given frequently, in very 
small doses, is found in many cases to have a distinctly beneficial effect. 
It reduces the temperature, promotes the action of the skin, and often 
quickly brings the inflammation to a close. The tincture should be used 
in doses of one drop in a teaspoonful of water every hour. Guaiacum is 
greatly praised by some authors. It can be given in doses of three or 
four grains in a teaspoonful of glycerine several times in the day ; or the 
child may suck a guaiacum lozenge every three or four hours. The salicy- 
late of soda is another remedy which has been lately held up as a specific 
in certain cases of quinsy. This drug, like the preceding, is especially 
adapted for cases which arise under the influence of cold and damp, and 
may therefore be supposed to be allied in their nature to rheumatism. To 
a child of ten years old it may be given in doses of ten or fifteen grains 
every four hours ; or half that quantity every two hours. If the salt be 



QUINSY — PROGNOSIS — TREATMENT. 589 

suspended in mucilage flavoured with tincture of orange peel, and sweet- 
ened with spirits of chloroform, the resulting mixture is not unpleasant to 
a child. If given sufficiently early, it is often found to shorten, in a re- 
markable manner, the course of the inflammation, and prevent suppuration. 
The old-fashioned treatment by salines, with moderate doses of antimonial 
wine, following the indispensable purge, finds favour with many practition- 
ers, and is no doubt often very successful. Attention to the bowels, in- 
deed, must never be neglected. A good dose of calomel, or gray powder, 
withcolocynthor jalapine, renders the after-course of the disease much less 
harassing, and, if all irritation of the throat is avoided, greatly helps the 
patient along in his path to recovery. 

Astringent gargles can only be allowed in the early stage of the disease. 
A solution of alum (twenty grains to the ounce) may be used in this way, 
but is only admissible if the febrile action is mild, and if the case is seen 
within the first twenty-four hours. At a later period, ordinary astringent 
applications often do much more harm than good. There is, however, an 
exception to this rule, for brushing the surface of the inflamed tonsils 
with the pure solution of the subacetate of lead is often attended with sur- 
prising relief to the discomfort. This application may be used once in the 
day, whatever be the period of the illness. Another application which is 
often of service is the bi-carbonate of soda, applied in the powder. An or- 
dinary throat brush, well charged with the powder, may be used to convey 
the latter to the tonsil. 

Directly signs of suppuration are noticed, the child should be made to in- 
hale the steam of hot water, and hot poultices should be sedulously applied 
to the throat. If old enough, the child should be directed to gargle fre- 
quently with warm water, to which, if there be any fcetor, a little Condy's 
fluid has been added. If necessary, the matter when it forms can be let 
out by a touch of the lancet, but in most cases it will be safe to allow it to 
find its own way to the surface. Still, if signs of dyspnoea are noticed, 
or the swelling is very large, operative interference is advisable. After the 
abscess has been evacuated, quinine should be given in full doses. 

The diet must consist at first of milk and broth. When the difficulty 
of swallowing becomes great, strong meat essence should be given, and the 
strength may be supported, if the child appear very weak, by the brandy- 
and-egg mixture, or port wine. In cases of the non-suppurative form of 
the disease, where, although the depression is great, febrile action is mod- 
erate, and the inflammation is accompanied by shallow ulcers on the tongue 
and cheeks, chlorate of potash is very useful, and may be given in doses of 
five to ten grains every three or four hours. These cases also are greatly 
benefited by purgation, and Epsom salts with quinine form a good combi- 
nation. A child of twelve years of age will take well two grains of quinine, 
with half a drachm of sulphate of magnesia, and five drops of dilute sul- 
phuric acid, every six hours. This treatment cleans the loaded tongue, and 
improves all ihe symptoms with remarkable quickness. In young children, 
too, a glass of port wine, given quite at the beginning of the attack, seems 
often to have the power of preventing any further development of the com- 
plaint. 

In the chronic form of tonsillar enlargement, it is of extreme importance 
to improve the general nutrition of the child. It will be usually found on 
inquiry that he suffers from repeated attacks of gastric derangement. Our 
first care must be to improve the condition of the digestive organs by the 
means recommended elsewhere (see Gastric Catarrh). A broad flannel band- 
age, to protect the stomach from chills, is here of extreme importance. 



590 DISEASE IN CHILDEEN. 

Usually, when the gastric mucous membrane has been restored to a healthy 
state, the general condition of the child improves, although the size of the 
tonsils has undergone no diminution. Cod-liver oil and iron wine, or qui- 
nine and tonics generally, may be given to hasten the return of flesh and 
strength. A little alcohol, in the form of light claret, is very useful in these 
cases. As special internal treatment of the swollen tonsils, Mr. Lennox 
Browne speaks highly of the influence of a combination of sulphide of cal- 
cium and iodoform (half a grain of each), given three times a day, in redu- 
cing the size of the glands. 

Of local measures, no doubt the best and most effective proceeding is 
excision. The tonsils having been removed, the tendency to catarrh in a 
great measure subsides ; the digestion improves ; the child begins to regain 
flesh and colour, and the congested state of the mucous membrane, which 
had been the source of so much discomfort and inconvenience, is at once 
relieved. The operation is a by no means painful one, and is followed by 
such immediate improvement that it should be recommended in every 
case. Often, however, the suggestion is not approved of by the parents, 
and other means of reducing the size of the glands will have to be resorted 
to. The tonsils may be painted twice a day with a mixture of equal parts 
of tinct. iodi and hq. potassae ; or once a day with the pure tinct. iodi. 
Powdered alum may be applied according to Quinart's method, rubbing it 
into the gland vigorously with the finger ; or the throat may be brushed 
twice a day with glycerine of tannin. These applications are, however, of 
doubtful efficacy. I have used them nryself, and seen them employed by 
others, but even if the size of the glands is reduced for a time by such 
means, the improvement is seldom a permanent one. Dr. Morell Macken- 
zie speaks highly of a paste composed of equal parts of caustic lime and 
soda with spirit. This is to be applied to different parts of the swollen 
surface once or twice a week. Other caustics, such as nitrate of silver, 
Vienna paste, and chloride of zinc (in the stick) have been used, and the 
galvano-cautery has also been employed. By the use of these agents, small 
portions of the enlarged and toughened glands are destroyed on each ap- 
plication ; but the size of the tonsils is but slowly reduced by this means 
— indeed, the patience of the child's relatives is usually exhausted before 
any definite results have been obtained. A more rapid method is that 
recommended by Dr. Gordon Holmes. A thin stick of nitrate of silver is 
pressed into the tonsillar crypts, and worked round for a few seconds. 
Small sloughs are thus formed, which are soon discharged. The process 
can be repeated every other day, and by this means, with little suffering to 
the child, for the operation is followed by but little external soreness of 
the throat, the size of the glands may be quickly and materially reduced. 
Another plan is to inject a solution of ergotin ( 3 j. — jss. to § j.) with the 
hypodermic syringe into the enlarged tonsil. Three to five drops may be 
slowly introduced into the gland once or twice a week. The operation 
seems to cause some pain, and is so greatly dreaded by the child that it is 
difficult to persevere with it for long together. I have never seen a case 
where the glands have been appreciably diminished by this means. 

French authors recommend sulphurous baths as efficacious in redu- 
cing the size of the glands, but I cannot speak from my own experience of 
the value of this method of treatment. 



CHAPTER Til. 

RETKOPHAEtYXGEAL ABSCESS. 

Collections of matter occasionally form in the loose cellular tissue at 
the back of the pharynx. The disease is of importance, as the abscess, by 
its situation, interferes seriously with the functions of respiration and deg- 
lutition, and gives rise to symptoms which, unless referred to their true 
origin, may be a source of considerable perplexity. 

Causation. — Ketro-pharyngeal abscess is more common in childhood 
than in after years, and during the first twelve months than at a later 
period of life. In eighty-nine cases collected by Gautier, nearly one-third 
of the patients were infants under a year old. 

Scrofulous tendencies appear to have a powerful influence in favouring 
the occurrence of the disease. In the subjects of this diathesis, the abscess 
is sometimes found to occur as a sequel of one of the acute specific diseases 
— of scarlatina, measles, diphtheria, or erysipelas. Caries of the cervical 
vertebrse, to which such children are prone, may induce it ; and it may 
follow tonsillitis, ulcerations about the mouth, or eczema of the scalp or 
back of the neck. In many cases, however, the cause of the malady is 
obscure. It has been attributed to exposure to cold, to the action of irri- 
tants, such as too hot liquids, and to injury from fish-bones, pins, and 
pointed spiculse of bone inadvertently swallowed. Indeed, such substances 
have been occasionally discovered in the contents of the abscess. 

Morbid Anatomy. — The collections of matter situated behind the pos- 
terior wall of the pharynx vary considerably in size. Sometimes they are 
as large as a hen's egg, and may even extend for a considerable distance 
upwards and downwards. They are not always seated in the middle line ; 
indeed, more commonly, perhaps, they are placed at an appreciable distance 
to one side. They are almost invariably single, and their contents consist 
of purulent and cheesy matter. Sometimes the abscess may open spon- 
taneously. In other cases it may set up ulceration in a large vessel, such 
as the carotid, and give rise to fatal haemorrhage. Occasionally it has 
been known to force its way along the cellular tissue of the neck, and open 
into the mediastinum or the pleural cavity. In a case which was under 
the care of my colleague, Mr. Parker, in the East London Children's Hospi- 
tal — a little boy fifteen months old — the abscess formed a fluctuating swel- 
ling, the size of a hen's egg, below and behind the angle of the lower jaw 
on the right side. There was also a soft, cushiony tumour at the back of 
the pharynx. After the abscess had been opened externally, pressure on 
the pharyngeal swelling caused pus to well up through, the wound. 

In young infants, the primary seat of the suppuration appears to be the 
lymphatic glands which lie along the posterior wall of the pharynx. Kor- 
mann states that with his finger he has been able to detect enlargement 
of these glands in certain cases of thrush, ulcerative stomatitis, ozsena, 
etc., but that only in one instance has he known the inflammation to pro- 



592 DISEASE IN CHILDREN. 

ceed to suppuration. Fleming, too, in 1850, attributed the postpharyn- 
geal suppurations to inflammation of these glands. 

Symptoms. — Unless the retro-pharyngeal abscess be due to caries of the 
cervical vertebrae, the case seldom comes under observation until some im- 
pediment to breathing has attracted the attention of the mother. The 
earlier symptoms are usually so indefinite that they excite very little notice. 
If, however, the purulent collection occurs as a consequence of suppura- 
tion of bone, the formation of the abscess is preceded by symptoms indica- 
cative of caries of the vertebrge of the neck. These symptoms have been 
described elsewhere (see page 178). 

Pain or difficulty in swallowing, is perhaps the first symptom observed. 
The presence of the pharyngeal swelling so interferes with the passage of 
food that the patient may have the greatest difficulty in taking nourish- 
ment. Liquids can often be swallowed, but solid matters pass only with 
great effort, or not at all. Sometimes the obstacle appears to be complete. 
In these cases, the child, if an infant, sucks eagerly for a few seconds, and 
then suddenly throwing back his head, discharges the fluid he has taken 
through the mouth and nose. As a consequence of the impediment, serious 
interference with nutrition invariably follows, and the child loses flesh rap- 
idly. It must be said, however, that cases are sometimes met with in which 
no difficulty of deglutition is present, and nutrition appears to be little 
affected by the presence of the abscess. 

Dyspnoea is another symptom which is usually to be noticed, and often 
occurs at the same time with the preceding. There appears to be direct 
interference with the entrance of air into the lungs, for at each inspiration 
the child makes a curious grating or whistling sound, and at the same 
time the soft parts of the chest sink in, and the epigastrium is retracted. 
The dyspnoea varies in degree. It is subject to paroxysmal exacerbations, 
but in the intervals the respiration is far from tranquil. "When the child 
lies down, the breathing is always especially difficult, and the dyspnoea is 
therefore particularly noticeable at night. In severe cases, the patient is 
obliged to raise himself in bed in order to breathe with any approach to 
ease, and may often be found sitting up in his cot with his legs doubled 
beneath his body. He cries fretfully if disturbed, or invited to take either 
food or drink, and will not willingly make any attempt to swallow. The 
dyspnoea is always increased when pressure is made externally upon the 
larynx. 

Cough is usually present, generally dry and hard, but sometimes par- 
oxysmal like the cough of pertussis. The voice has a nasal quality, espe- 
cially if the swelling is high up in the pharynx. It is seldom hoarse if the 
case be uncomplicated. 

Stiffness of the neck is a characteristic symptom, for movement of the 
head upon the shoulders is always painful. Consequently, the child holds 
the head in a curiously rigid way, sometimes inclined to one side or bent 
somewhat backwards. When the neck is examined, it is often found to be 
swollen. Sometimes the depression behind the angle of the jaw is obliter- 
ated, and Mondiere points to this as a characteristic symptom. Sometimes 
the larynx is pushed forwards, or forced to one side out of the middle line. 
Pressure upon the neck or larynx is always painful. 

On inspecting the throat, a swelling can usually be seen at the back of 
the pharynx, protruding from beneath the soft palate, and seeming to 
touch the back of the tongue. The mucous membrane may not be altered 
in colour, and often there is no redness of the fauces. On touching the 
swelling with the finger, it is usually felt to be soft and elastic like a sac 



RETROPHARYNGEAL ABSCESS— SYMPTOMS. 593 

filled with fluid, but may feel firm like a solid growth. The finger should 
be passed round the borders of the prominence so as to define its limits. 
The swelling does not always come into view when the mouth is opened ; 
for not only is it often obscured by more or less frothy mucus, but its situ- 
ation may be such that it is not readily discovered. If, then, we suspect 
its existence, the finger should be rapidly passed upwards to the back of 
the nose, and downwards behind the glottis. By this means the position 
of the abscess can usually be ascertained. 

The above symptoms are to be discovered in most cases of the disease ; 
but the course and form of the illness vary greatly according to whether 
the suppuration is an acute or chronic lesion. 

In an acute suppuration behind the pharynx the symptoms are very 
much more pressing and severe than in the more chronic form of retro- 
pharyngeal abscess. The disease generally begins with high fever, severe 
headache, and vomiting. After a few days, stiffness of the muscles of the 
neck is noticed, with a peculiar fixed position of the head, and there may 
be swelling of the neck and great tenderness. In some cases, the stiffness 
extends to the muscles of the jaw, so that the mouth can be opened only 
imperfectly. At the same time, or soon afterwards, there is difficulty in 
swallowing, and the breathing is laboured and stertorous. If the child is 
laid down these symptoms are increased, and often the recumbent position 
induces a state of somnolence approaching to stupor. If the symptoms are 
not relieved, the condition of the child becomes more and more distressed. 
His face is swollen and livid, and the jugular veins are prominent. He 
lingers for a few days in this state, and then dies, exhausted from inanition, 
or suffocated in a paroxysm of dyspnoea. Death is often preceded by a se- 
ries of convulsive attacks. 

In the more chronic cases, there is little or no fever, and the symptoms 
generally are much less urgent. There is, however, usually a noticeable 
interference with nutrition, and the loss of flesh is considerable. 

The duration of the disease varies greatly. In some cases it runs a 
very acute course, and ends fatally in a fortnight or three weeks. This 
form is most common when the suppuration occurs as a sequel of fever. 
In other cases, the dyspnoea and dysphagia continue for months before 
their true significance is realised. 

A little girl, aged three years, was brought to me at the hospital for 
difficulty of breathing. The mother stated that two years previously, 
while teething, the child had suffered from an eruption on the head. This 
had been quickly followed by a swelling at the right side of the neck, 
which, after growing larger for two months, had burst. Very shortly af- 
terwards the breathing had been noticed to be oppressed, and the respi- 
ration had begun to be accompanied by a peculiar whistling or rattling 
noise. This symptom had continued ever since, and was always worse at 
night. The child was said to sleep very heavily, with her eyes only 
partially closed. Sometimes she had seemed to have a difficulty in swal- 
lowing. 

When first seen, the child was lying asleep, resting on the right side of 
her chest. She was sweating profusely about the head and neck. Her 
face was flushed, and the eyes were only partially closed. The mouth was 
open, and the nares were motionless in respiration. At each breath the in- 
tercostal spaces sank in deeply, and the epigastrium was depressed. With 
each inspiration a peculiar grating noise was heard, which seemed to pro- 
ceed from the throat. The expirations were less noisy, but still abnormal. 
The glands along the edge of the sterno-mastoid, and those below the jaw, 
38 



594 DISEASE IN CHILDREN. 

were enlarged and painless, and the larynx and trachea seemed pushed out 
of the middle line to the left. 

On inspecting the fauces, a swelling about the size of a plover's egg could 
be seen at the back of the pharynx. On pressing this with the finger, it 
felt firm like a solid tumour. 

The swelling was punctured with a large trocar and canula, and half 
an ounce of thick pus was evacuated. After the operation the breathing 
became quieter, and swallowing was effected without difficulty. The ab- 
scess continued to discharge for some days and then healed. When the 
child left the hospital she seemed well in health, but some thickening re- 
mained at the back of the pharynx. 

In this case, the disease had lasted for two years, and was apparently 
the consequence of slow softening of a cheesy gland at the back of the 
pharynx. The cervical glands were also enlarged and caseous ; and from 
one of these, seated behind the angle of the jaw, a quantity of cheesy mat- 
ter was scooped out by my colleague, Mr. Eeeves. 

Whatever be the length of its course, a retro-pharyngeal abscess, if un- 
recognised, generally terminates in death. As has been before remarked, 
the child usually dies suffocated in a paroxysm of dyspnoea, or gradually 
wastes away from starvation and exhaustion. Even spontaneous bursting 
of the abscess appears to be attended with great danger, and cases are re- 
ported in which suffocation has been the consequence of the passage of the 
purulent matter into the trachea. 

Diagnosis. — Amongst the various causes of dyspnoea in the child, it must 
not be forgotten that retro-pharyngeal abscess is one ; and in every case 
where the breathing is difficult and stertorous, the pharynx should be ex- 
amined as a matter of routine. If this be done, the disease is not likely 
to be overlooked, for a finger passed to the back of the pharynx at once 
detects the presence of the abscess. Moreover, information may be some- 
times gained from mere inspection of the neck. Any unusual prominence of 
the trachea, or displacement of that tube to the right or left of the middle 
line, suggests an extra-laryngeal cause for the dyspnoea. So, also, if we 
find the child sitting up in bed and refusing to lie down ; or if laid down, 
starting up again in an access of suffocation, we should suspect external 
pressure upon the larynx. The more characteristic symptoms are : Stiff- 
ness and swelling of the neck, and difficulty of swallowing, combined with 
orthopncea and stridulous breathing. The most characteristic sign is a 
swelling at the back of the pharynx, which is not, indeed, always to be seen, 
but can invariably be felt by digital exploration. 

The disease is more likely to be misapprehended in the acute than in 
the chronic form ; for the violence of the symptoms, the lividity of the 
face, the urgency of the dyspnoea, and the stertorous character of the breath- 
ing, suggest the presence of membranous croup. But in that disease, stertor 
is present from the beginning ; the dyspnoea is not increased by pressure 
made upon the trachea, and is relieved when the head is low ; the voice 
rapidly becomes hoarse and then whispering ; and unless the pharynx be 
the seat of false membrane, there is no difficulty in swallowing. 

(Edema of the glottis also presents many points of similarity with 
abscess of the pharynx ; but in the former case the stridor is only marked 
in inspiration, the expiration being noiseless ; and when the finger is 
passed into the throat it detects no tumour, but can feel the thickened 
epiglottis and the swollen ary-epiglottidean folds. Still, the two diseases 
may be present together ; but if a tumour can be felt at the back of the phar- 
ynx on digital examination, the nature of the disease cannot be doubtful. 



RETRO -PHARYNGEAL ABSCESS — PROGNOSIS — TREATMENT. 595 

Prognosis. — If the abscess is detected in time, the prognosis is favoura- 
ble. When death occurs in this disease, it is usually in cases where the 
cause of the symptoms has been overlooked, and no attempt has been 
made to relieve the child by the only means which are likely to prove ef- 
fectual. The worst cases are those in which the abscess is the consequence 
of careous disease of bone ; but even these may end in recovery if the 
matter be evacuated before the child has become exhausted. 

Treatment. — In the treatment of retro-pharyngeal abscess, no time should 
be lost. Directly the tumour is recognised, it should be opened, whether 
fluctuation be present or not. In order to avoid any risk of penetration of 
the pus into the larynx, it is perhaps safer to use a large trocar and can- 
ula ; but the abscess may be opened with a knife without danger if care 
be taken to bend the child's head promptly forwards when the incision 
is made. The bistoury should be guarded to within half an inch of its 
point by winding adhesive plaster round the blade. The opening must be 
made as near the middle line as possible ; and the instrument may be 
pushed boldly forwards, for the pus often lies at some distance from the 
surface. If a trocar be used, the abscess sometimes refills, and may require 
a second puncture after a few days. 

The general health of the child must be attended to. Good diet and a 
certain quantity of stimulant should be allowed ; and he may take quinine 
and cod-liver oil. When convalescent, the patient will be benefited by a 
visit to the seaside. 



Part 9. 
DISEASES OF THE DIGESTIVE ORGANS, 



CHAPTEE I. 

INFANTILE ATROPHY. 



Infantile atrophy, or the slow wasting which is a familiar symptom in 
hand-fed babies, is one of the commonest causes of death in early infancy. 
The child ceases to digest his food — possibly he has never begun to do so ; 
gradually dwindles away, and after a longer or shorter period, dies with 
all the symptoms of starvation. This condition, which, under the name of 
" marasmus," finds a large place in the mortality returns of all countries, 
is a perfectly curable complaint, and may be arrested at almost any stage 
by the exercise of judgment and care in the feeding and general manage- 
ment of the infant. 

Causation. — Infantile atrophy is the consequence of insufficient nourish- 
ment. The child wastes because he is starved. But it is not to actual 
lack of feeding that the starvation is usually to be ascribed. A baby 
fed from a breast which secretes milk poor in quality and insufficient for 
the child's support, will, of course, grow slowly thinner ; but an infant sup- 
plied largely with farinaceous compounds from which his feeble digestive 
organs fail to derive even a minimum of nourishment, will waste with start- 
ling rapidity. Starvation is then a relative term. The tissues may be 
starved, although the stomach is regularly filled. In eveiw case, the nutri- 
tion of the infant is dependent upon his power of extracting a sufficiency 
of nourishment from his so-called " food." It may seem unnecessary to 
insist upon so self-evident a matter ; but in practice it is common to find a 
diet persisted with which the infant's stomach rejects, or his tissues fail to 
assimilate. Many a baby's life is sacrificed through the inability of those 
about the child to understand that feeding and nourishing are not quite 
the same thing. 

For efficient nourishment, four classes of substance are indispensable, 
viz., albuminates, hydro-carbonates, fats, and salts. It is further necessary 
that these should be presented to the child in such a form that they can be 
digested with ease. The most perfect- food for infants — the only one, in 
fact, which can be relied upon in itself to furnish all these requirements — is 
milk. Milk contains nitrogenous matter in the curd, fat in the cream, be- 



INFANTILE ATEOPHY — CAUSATION. 



597 



sides sugar and the salts which are essential to perfect nutrition. In the 
milk of the mother or of a good nurse the new-born infant finds these ele- 
ments combined in exactly the proportions best adapted to supply all the 
wants of his system. In the milk of animals, the proportions deviate more 
or less widely frdni the human standard. Cow's milk, especially, contains 
a larger proportion of curd and cream than is found in human milk, but 
less sugar ; and although to an exceptionally sturdy infant this difference 
may be immaterial, for a child of ordinary powers it will be necessary, by 
suitable preparation, to bring the milk into closer resemblance with the 
natural diet of which he has been deprived. 

The chief obstacle to the digestion of cow's milk by young babies is not, 
however, the mere difference in the proportion of the several constituents. 
Were this so, dilution with water and the addition of sugar of milk would 
be sufficient to perfect the resemblance between the two fluids. A more 
important difference is the denseness of the clot formed by the curd of 
cow's milk. Ample dilution with water does not affect this property. Un- 
der the action of the gastric juice, the particles of casein still run together 
into a solid, compact lump. This is not the case with milk from the breast 
Human milk forms a light, loose llocculent clot, which is readily disinte- 
grated and digested in the stomach. The difficulty which even the strong- 
est children find in digesting cow's milk, is shown by the masses of hard 
curd which a child fed exclusively upon this diet passes daily from the 
bowels. This difference between the two milks is answerable for much of the 
trouble and disappointment experienced in bringing up infants by hand. 
But it is not merely new-born infants for whom a diet of cow's milk is inap- 
propriate. Gastric and intestinal disorders often date from the time of 
weaning ; and this is partly the consequence of an abrupt change from 
human to cow's milk in cases where little or no care is taken to make the 
new diet a digestible one. The heavy curd of cow's milk is often difficult 
of digestion, even by children of ten or twelve months old, if they have been 
accustomed only to the breast ; and unless measures are adopted to hinder 
the firm clotting of the casein, serious dangers may arise. 

The difference in the constitution of the milk of the woman, the cow, 
the ass, and the goat, are seen in the following table prepared by MM. Yer- 
nois and Becquerel : — 





Sp. Gr. 


Water. 


Solids. 


Sugar. 


Casein 
and Ex- 
tractives. 


Butter. 


Salts. 

i 


Woman 

Cow 


1032.67 
1033.38 
1034.57 
1033.53 


889.08 
864.06 
890.12 
844.90 


110.92 
135.94 

107.88 
153.10 


43.64 
38.03 
50.46 
36.91 


39.24 
55.15 
35.65 
55.14 


26.66 
36.14 
18.53 
56.87 


1.38 
6.64 


Ass 


5.24 


Goat 


6.18 



The milk of the ass approximates most nearly in composition to that 
of the human breast, and is much more digestible than the milk of the 
cow. The goat yields a milk which chemically resembles very closely that 
of the cow, but in practice it is found to be far more digestible by the 
child. This is no doubt due to the looser clot formed in the stomach by 
its coagulated curd. 

As cow's milk diluted with water is considerably less digestible than the 



598 DISEASE IN CHILDREN. 

milk of the human breast, it is not surprising that a weakly child should 
fail to derive sufficient nourishment from such a diet. If he be fed with 
large quantities of farinaceous food, his difficulties are still further in- 
creased. The new-born infant has only a feeble capacity for digesting 
starch. His salivary secretion is excessively scanty, and his pancreas can 
scarcely be said to furnish any secretion at all. According to the experi- 
ments of Korowin, of St. Petersburg, it is not until the end of the third 
month after birth that the pancreatic fluid is found to have any appreciable 
action upon starch. The two secretions upon which the digestion of starch 
chiefly depends are therefore almost completely absent in early infancy. Yet 
it is to a being quite unprepared by nature for this diet that farinaceous 
substances under the misleading name of "Infants' Foods" are so univer- 
sally given. Many babies are fed with them exclusively from their birth ; 
others take them in large quantities as an addition to the breast-milk. In 
either case, the meal is in great part undigested, and gives rise to much flatu- 
lence and pain in its passage along the alimentary canal. It must be borne 
in mind that the effect of an indigestible diet is not merely the withhold- 
ing of nourishment. To the weakness of starvation or semi-starvation 
must be joined the additional weakness induced by catarrh of mucous 
membrane from the constant passage along the bowel of undigested and 
fermenting food. The irritation thus set up gives rise to repeated attacks 
of vomiting and diarrhoea ; and even between the attacks, although the 
irritation is for the time less severe, the child is restless and uncomfort- 
able, crying and whining, and unable to sleep from the colicky pains in his 
belly. Unfortunately for the infant, this consequence of his unsuitable 
diet is often mistaken by ignorant or too anxious attendants for signs of 
hunger ; and while the poor sufferer is still labouring to dispose of his last 
meal, another supply of food, which his craving forces him eagerly to swal- 
low, increases his difficulty and discomfort. It is not, then, surprising that 
the infant, extracting no nourishment from his frequent meals, grows daily 
thinner and more feeble, and sinks at last, worn out by purging, pain, and 
want of sleep. 

The symptoms of indigestion which always precede the more pro- 
nounced signs of infantile atrophy, sometimes come on quite suddenly and 
unexpectedly in an infant who has been fed with judgment, and has at 
first appeared to thrive. The falling off is due, in the majority of cases, to 
some casual derangement of the stomach and bowels which induces an 
acid change in his food. The child consequently ceases to be able to di- 
gest his milk. The fluid undergoes fermentation in his stomach, and gen- 
erates an acid which irritates the delicate mucous membrane and increases 
the disturbance of the digestive organs. Severe symptoms are often the 
consequence of this indigestion, so that, unless timely measures are taken 
to avert the danger, the child's life may be sacrificed. An attack of gas- 
tric catarrh, induced by a slight chill, is the commonest cause of this sud- 
den indigestion ; but sometimes the derangement is the result of over- 
feeding, the child's meals being too large or too frequently repeated ; or, 
again, the feeding apparatus may have been neglected, so that milk put 
into a dirty, sour bottle, has begun to ferment before the child swallows it. 
In warm weather, milk soon becomes sour, even in clean vessels ; indeed, 
if some time have elapsed since the milk was drawn fTom the udder, it 
may be delivered at the house in a slightly acid state, although appearing 
to be perfectly fresh to the eye, the smell, and even to the taste. 

There is one other cause of infantile indigestion and bowel complaint 
which should be mentioned, as the fault is a common one. In households 



INFANTILE ATROPHY— CAUSATION. 599 

where it is the custom to prepare for the infant in the morning the whole 
day's supply of food, an acid change in the mixture almost invariably takes 
place, so that in the afternoon or evening the food is no longer fit for the 
child's consumption. The change may occur without 'necessarily produ- 
cing any alteration appreciable by the senses. Test paper will, however, 
show acidity, and the microscope will probably reveal bacteria in active 
motion. 

A derangement of the stomach and bowels, occurring suddenly from 
any of these causes, not only interferes with the infant's nutrition for the 
time, but often produces much more serious consequences. It may set up 
a disorder in the digestive system which is never afterwards recovered 
from, and start a process of gradual wasting which ends only with the 
death of the child. It is, indeed, in incidents of this kind that the chief 
danger of artificial feeding consists ; for a diet arranged originally with 
care and judgment ceases to be appropriate in these altered conditions. 
An immediate change is imperative if the derangement is to be remedied ; 
and for some time afterwards a careful watch must be kept over the in- 
fant's digestion, lest the disorder return. 

Infantile atrophy is seldom seen to any serious extent in infants at the 
breast, but sometimes a certain degree of malnutrition is observable in 
babies who take no other food. This may result from different causes. 
An infant may be consigned to a wet-nurse whose own child is much older 
than her adopted suckling. It is well-known that, as time passes, human 
milk becomes proportionately richer in curd and cream. An infant, new- 
born, and with naturally feeble digestive power, put to the breast at a late 
period of lactation, may consequently fail to thrive ; or may even suffer 
from indigestion and bowel complaint through the richness of the milk. 
Again, in some women, the milk, although abundant, is of poor quality, and 
insufficient for the support of a strong baby, so that the child soon shows 
signs of deficient nutrition. Human milk is also affected by dietetic and 
emotional causes, and the secretion is apt to be influenced by the general 
state of health. There are many reasons, therefore, why a child, even while 
at the breast, should be subject to casual derangements. Still, these are 
usually trifling, and seldom produce any serious effect upon his nutrition. 

It sometimes happens that a mother's milk is not well suited for the 
nourishment of her offspring, even in cases where the secretion is copious, 
the child a sturdy boy, and the health of the mother in every way satisfac- 
tory. Some years ago I was asked by a gentleman to go and see his child 
— a little boy of seven months of age. I found that the child had been 
suffering for some weeks from severe abdominal pains. He was excessive- 
ly peevish and fretful, and at night would wake up with a scream, and twist 
about his body under the influence of severe griping pain. His bowels 
were very confined, and the motions consisted almost entirely of curd. He 
was taking nothing but the breast. Aperients had been found to relieve 
the child for a time, but the symptoms always returned when the effect of 
the purgative had passed away. Whenever the breast was stopped for a 
few days, he immediately improved, but relapsed as soon as suckling was 
resumed. The child had lost flesh, and was evidently suffering from his 
inability to digest the curd of his mother's milk. It was therefore a matter 
of great importance to enable him to do so ; otherwise he would have to be 
weaned, and fed in a different way. The mother had herself, by taking salines 
and other medicines, and by making many modifications in her diet under 
medical advice, endeavoured to alter the quality of her milk, but without 
success. 



600 DISEASE IN CHILDREN. 

Several methods of remedying the evil were tried. The intervals between 
the times of suckling were increased, so as to give a longer period for di- 
gestion ; but this change had no effect whatever. Alternate meals of barley- 
water were then given from a feeding-bottle. By this means, the quantity 
of milk taken by the child in the course of the day was diminished, and 
the interval between the times of suckling was still further increased. No 
improvement, however, followed the alteration. The griping pains still 
continued, and the constant fretfulness of the child was most distressing 
to the mother. The plan was at last adopted of giving the child barley- 
water from a bottle immediately before he took the breast, in the hope that 
by this means the milk might be diluted directly it reached the stomach. 
This method succeeded perfectly, and the child had no further unpleasant 
symptoms. 

In this instance, the infant's stomach was in a perfectly healthy state. The 
fault lay in the mother's milk, which was too heavy for the child's powers of 
digestion. In the large majority of cases of indigestion in infants reared 
at the breast, the fault is in the digestive organs of the child, an attack of 
gastric catarrh having rendered him for the time incapable of digesting his 
mother's milk. In these cases, the indigestion is a temporary failing, and 
is easily remedied b}*" suitable treatment. Without judicious management, 
the derangement may be prolonged indefinitely ; and it not unfrequently 
happens that the mother is directed to wean her baby under the mistaken 
notion that her milk is unfit for its support. 

Morbid Anatomy. — In cases of death from infantile atrophy, the tissues 
are found excessively wasted, and there is complete absence of adipose tissue 
from the body. The general pathological appearances are such as have 
been already described as common to cases of thrush (see page 572). 

Symptoms. — When a child at the breast depends for his support upon 
a scanty supply of poor milk, he suffers no pain, but wastes persistently. 
The infant is peevish from hunger, and at times cries violently. For the 
same reason he sleeps little, and at night is very troublesome. In the day- 
time he often lies quietly sucking his fingers until they are raw. His fon- 
tanelle is level or depressed ; his skin is moist ; his bowels are confined ; 
the motions scanty and often almost solid. He soon becomes pale and 
flabby, and does not grow. If the milk, although poor and watery, is abun- 
dant, the child frequently requires the breast. He sleeps much, and often is 
found asleep with the nipple still in his mouth. This, indeed, is a common 
sign of watery milk. If noticed in a child who is not thriving, but in whom 
no positive derangement can be discovered, measures should at once be 
taken to change the nurse, or supplement the breast-milk by a suitable diet. 

In hand-fed babies, infantile atrophy is often seen in its most extreme 
degree. A child fed with unsuitable food is not only starved, but is kept 
in a state of continual distress ; so that we find persistent wasting com- 
bined with symptoms more or less striking of gastric and intestinal dis- 
turbance. 

The loss of flesh is noticed from the very beginning. Its rapidity de- 
pends partly upon the kind of food chosen ; partly upon the natural 
strength of the child, and his capacity for extracting nourishment from 
his unwholesome diet. A puny infant, fed with large quantities of arrow- 
root, or other equally inappropriate food, wastes very rapidly, and at the 
end of two or three months, if he lives so long, may actually appear to 
have made no advance in size or in strength since his birth. Such an in- 
fant is pale and miserably thin, his skin is dry, and has a faint yellow tint ; 
his eye^ are hollow ; his cheek-bones project ; his lips are livid, and their 



INFANTILE ATROPHY — SYMPTOMS. 601 

slightest movement shows a deep furrow encircling the comers of the 
mouth ; his expression is uneasy and languid ; his feet and hands are habit- 
ually cold, and he whines and cries fretfully for hours together. These 
children often have a ravenous appetite for food, and will swallow greedily 
whatever is offered to them. The meal, however, produces merely a tem- 
porary relief, and as soon as the griping pains to which it gives rise make 
themselves felt, the child's wailings are renewed. The abdominal pains 
excited by the indigestible nature of his food are often very severe. The 
infant may become quite stiff and rigid from his suffering, and scream 
with white, drawn face and staring eyes until exhausted. Sometimes the 
griping gives rise to a convulsive lit, although this is rare, but the irrita- 
tion of the bow r els, and acidity, not unfrequently excite signs of nervous 
irritation ; we notice sudden starts and twitches, a slight squint, a pecu- 
liar rotation of the eyeball upwards, and contractions of the fingers and 
toes. 

Eruptions on the skin, such as strophulus and urticaria, are common ; 
and in the later stage of the illness, aphthae or thrush may appear in the 
mouth. 

The state of the bowels varies. It is probably dependent upon the de- 
gree to which the mucous membrane is irritated by the child's unsuitable 
diet. If this irritation be only moderate, the bowels are usually confined. 
The infant is restless, and may be noticed to be feverish at night. His 
tongue is coated with a thick white fur. He is evidently in a state of 
great discomfort, for his temper is peevish and fretful, his movements are 
uneasy and jerking, and he occasionally breaks out into piercing cries, 
drawing up his knees and twisting about his body under the influence of 
abdominal pain. At night the griping is especially violent ; the child 
scarcely sleeps at all, or if he be quiet for a moment in uneasy sleep, he 
soon starts up again, screaming with a fresh attack of pain. The motions 
are scanty and rare. The bowels sometimes remain confined for twenty- 
four hours or longer, and when they are at last relieved, hard, clay-col- 
oured balls, tinged with green mucus, are expelled with great effort and 
straining. These balls consist of hard curd and farinaceous matter. A 
full dose of castor-oil, which clears away the curd, allays the symptoms 
for a time ; but usually, if the same diet be persisted in without any 
change, they return in a day or Wo, and the child is in the same distress 
as before. 

In almost all cases of infantile atrophy, the ordinary uniform course of 
the derangement is interrupted by intercurrent attacks of vomiting and 
diarrhoea. These attacks not only greatly increase the rapidity of the 
wasting, but, if of great severity, may bring the illness abruptly to an end. 

Troublesome vomiting in a young baby, the consequence of gastric 
catarrh, is a very serious ailment. All food swallowed is instantly re- 
turned, and clear fluid, like water, or bile-stained mucus, is occasionally 
ejected. The vomited matters, and even the breath of the child, have an 
offensive, sour smell. The belly is swollen and often seems tender; the 
hands and feet are very difficult to keep warm ; the eyes grow quickly hol- 
low; the lids close imperfectly; the complexion is sallow or half jaundiced, 
and the fontanelle is deeply depressed. At first the tongue is thickly 
furred, later it is apt to have "a red, glazed appearance. The child is very 
fretful. He soon becomes too weak to cry loudly, but whimpers feebly to 
himself in a pitiful way, and scarcely seems to sleep at all. If no diarrhoea 
complicate the ailment, the bowels are confined, and the patient often 
seems to be disturbed by flatulence, for he draws up his legs uneasily 



602 DISEASE IN CHILDREN. 

with a troubled grimace. If treatment do not succeed in checking the 
disorder, the vomiting continues, and is excited by the least movement. 
The complexion becomes earthy, the hands and feet grow purple, and the 
temperature in the rectum may fall as low as 96° or 97°. At this period, 
thrush usually appears in the mouth, and death may be preceded by 
symptoms of spurious hydrocephalus. 

Steady, persistent vomiting such as has been described, is less common , 
than are shorter attacks of sickness accompanied by diarrhoea. These are 
apt to occur in children at an early period of the atrophy, and must be 
looked upon as an effort of nature to relieve the alimentary canal of its 
unwholesome burden. It is only at a later period of the illness that they 
are apt to become obstinate, and when thus confirmed, the ailment is very 
difficult to overcome. A chronic diarrhoea, such as is elsewhere described 
(see page 633), often arises in the course of infantile atrophy, and, if not 
treated judiciously, determines a fatal issue to the illness. In most cases, 
indeed, death is the consequence of a persistent looseness of the bowels 
which nothing will arrest. But, in an infant reduced to a weakly state by 
a long course of improper food, any acute ailment, however apparently 
trifling it may be, will often prove fatal. A new symptom occurring at a 
late period of atrophy is therefore to be regarded with very serious ap- 
prehension. 

Diagnosis. — A state of extreme emaciation may be present in the infant 
as a result of other causes than injudicious management and unwholesome 
feeding. Infants, the subjects of inherited syphilis, are often excessively 
puny and feeble, and acute tuberculosis may attack a child of a few 
months old and gravely impair the nutrition of the patient. 

In the first case, the symptoms induced by the syphilitic poison are 
sufficiently distinct. The child snuffles and cries hoarsely. His skin is dry, 
wrinkled, and of the colour of old parchment. It is sprinkled over with 
the characteristic coppery or rust-coloured spots, and the buttocks and 
perinseum, often, also, the genitals and upper parts of the thighs, are the 
colour of the lean of ham. Mucous tubercles are probably to be discovered 
at the margin of the anus and the lips. The corners of the mouth are 
fissured, and the nostrils red-looking and excoriated. The bridge of the 
nose is flattened, and an examination of the belly will probably detect 
enlargement of the spleen. None of these symptoms are to be found in 
simple infantile atrophy. The earthy tint of the face and bod}' sometimes 
resulting from chronic digestive trouble is very different from the parch- 
ment-like hue of the inherited disease ; strophulus, arising from the same 
cause, can hardly be mistaken for the coppery spots of syphilis ; and hoarse- 
ness, snuffling, and the other symptoms which have been enumerated, are 
never the consequence of weakness and wasting, however profound. 

In acute tuberculosis, the temperature is elevated, and a thermometer 
in the rectum will be found to mark 100° or 101° in the evening. In in- 
fantile atrophy, there is ho pyrexia ; on the contrary, the bodily heat is 
usually lower than in health. Moreover, in the former disease, the child 
coughs, and even if the lungs are not the seat of pneumonia, a clicking 
rhonchus will be discovered here and there about the chest. In tuber- 
culosis, too, a slight amount of oedema of the legs is almost invariably 
present in the infant. 

Syphilis and tuberculosis having been excluded, the diagnosis is easy. 
The wasting must be due to chronic digestive derangement, or to unsuit- 
able food, or to both of these causes combined. In the case of either 
chronic vomiting or chronic diarrhoea, the characteristic symptom of these 



INFANTILE ATROPHY— PROGNOSIS — TREATMENT. 603 

derangements will be present. Still, in many cases of malnutrition, where 
the wasting is extreme, there is no irritability of stomach, and the bowels 
are habitually confined. In these cases the child is peevish and fretful. 
His belly is distended, and his skin dry and dull-looking. The nasal line 
encircling the corners of his mouth is well-defined. His feet are often 
cold, and the bodily temperature in the rectum is sub-normal (97°-97.5°). 
His stools consist of hard light-coloured balls, or of unformed putty-like 
matter. The child is subject to attacks of abdominal pain, and is very 
noisy and troublesome at night. 

Prognosis. — Unless the infant be reduced to a state of extreme weak- 
ness and depression, the prognosis is not unfavourable. It is often surpris- 
ing to mark the immediate improvement which takes place when the child 
is put to the breast, or is supplied with a food he is capable of digesting. 
If signs of spurious hydrocephalus have been noticed, if the mouth be the 
seat of thrush, or if a chronic diarrhoea have been established, the progno- 
sis is more serious, and, indeed, these cases often end unfavourably. 
Chronic vomiting, however, can usually be arrested by judicious treatment, 
if the infant retain sufficient strength to respond to the restorative meas- 
ures adopted. 

Treatment. — Li endeavouring to improve the nutrition of a child who 
is suffering from infantile atrophy, we have to take into account the degree 
of weakness of the infant, and the more or less disordered state of his diges- 
tive organs. If a wet nurse can be procured, a return to the breast, if the 
child can be persuaded to take it, usually arrests at once all unfavourable 
symptoms ; especially, if the alteration in the mode of feeding be aided by 
an aperient dose of castor-oil, followed by an antacid and stomachic mix- 
ture. In many cases, however, this method of treatment is not within our 
reach, and we have to trust to a judicious revision of the child's dietary 
and general management. 

The successful rearing of an infant by artificial means is not a difficult 
matter. It requires intelligence and tact ; but, above all, it requires watch- 
fulness. If we are vigilant to detect the first signs of discomfort and acid- 
ity, and at once modify the diet accordingly, we may be sure of preserv- 
ing a healthy tone in the stomach, and warding off all the accidents to 
which a child less carefully nurtured might possibly succumb. 

During the first month after birth, the infant usually is able to obtain 
some milk from its mother's breast. This, however, may have to be sup- 
plemented by other food, and sometimes the babe is forced to depend 
entirely upon artificial feeding from the beginning. For the first six 
weeks he may be fed with condensed milk diluted with water, or thin bar- 
ley-water, in the proportion of one teaspoonful of the milk to the half bot- 
tle. Preserved milk at this time almost invariably agrees well. Care must, 
however, be taken to use only milk from a tin which has been newly- 
opened ; for when exposed to the air, the milk, although still apparently 
fresh, rapidly breeds bacteria, and becomes unfit for the child's consump- 
tion. In hot weather, too, the barley-water should be freshly made twice 
in the day. Like the condensed milk, it must be kept in a refrigerator or 
other cool place, and should never be heated to the boiling point after it 
has once been made, as to do so excites rapid fermentation. 

After six weeks, or, at the most, two months, have elapsed from birth, the 
child should be put upon cow's milk. It is important, especially in warm 
weather, that this should be perfectly fresh. If slightly acid from keep- 
ing, as it often is when delivered at the house, the acidity should be neutral- 
ised by the addition of a little carbonate of soda. 



604 DISEASE IN CHILDKEN. 

To make this milk an efficient substitute for human breast-milk, it will 
not be sufficient to sweeten it with sugar and dilute it with water. It is 
necessary, in addition, to prevent the firm clotting of its curd under the 
action of the gastric juice. This may be done by using lime-water to di- 
lute the milk, adding it in sufficient quantity to partially neutralise the 
gastric secretion, and thus in a great measure prevent coagulation in the 
stomach. To do this effectually, at least a third-part of the mixture should 
consist of lime-water. To two tablespoonfuls of fresh milk, add an equal 
quantity of hot filtered water, and alkalinise by two tablespoonfuls of lime- 
water. The infant should suck this food from a feeding-bottle. Its tem- 
perature when taken should be 95°. If too cool after being prepared, the 
feeding-bottle should be allowed to stand for a few minutes in a little 
basinful of hot water. 

Another plan by which the casein of cow's milk may be made digest- 
ible, consists in mechanically separating the particles of curd by the addi- 
tion of some thickening substance, such as gelatine or barley-water. This 
method of preparing the milk is to be preferred to the previous one, as it 
leaves the gastric juice unaltered, and does nothing to impair the child's 
digestive power. It merely forces the curd to form a multitude of small 
clots, instead of running together into one large, dense lump. For a child 
of two months of age, the milk should be diluted with an equal quantity 
of barley-water, and be sweetened with a small teaspoonful of sugar of 
milk. 

The proportion of milk taken by the infant for each meal should be 
gradually increased as he grows older. From a half, the quantity may rise 
by degrees to two-thirds, and then to three-fourths, and a larger quantity 
of milk-sugar may also be added. 

Barley-water rarely disagrees even with the youngest infants, although 
in them the capacity for digesting starch is very feeble, as has been already 
explained. If preferred, however, instead of barley-water, the milk may 
be diluted with plain water, and the thickening material be supplied by a 
teaspoonful of isinglass or gelatine. Mellin's food, too, may be used from 
the first, and is almost always well digested. 

Farinaceous matters, unless guarded by malt, as in Mellin's food, should 
not be given to a child younger than six months. 

The milk prepared in one of the ways described must be given in suit- 
able quantities and at regular intervals. Six or eight tablespoonfuls will 
be enough to make a meal for an infant of four or five weeks old. The 
child should take his food half reclining, as when in his mother's arms, 
and the bottle must be removed directly its contents are exhausted. After 
taking his food, the child should sleep for two hours. Any sign of fretful- 
ness or discomfort at this age must be taken to imply indigestion and 
flatulence. If this be the case, a teaspoonful of some aromatic water, such 
as cinnamon or dill, may be added to the next bottle of food. The feeding 
apparatus must be kept perfectly clean. It is well to wash out the bottle 
directly after it has been used, with soda and water, and then to let it stand 
in cold water until again required. It is desirable to have two bottles and 
to use them alternately. 

When the child is six months of age he may begin to take farinaceous 
food. A teaspoonful of Chapman's entire wheaten flour, baked in an oven, 
can be given once or twice a day, rubbed up, not boiled, with milk. If 
there is constipation, a similar quantity of fine oatmeal may be used in- 
stead of the flour. When the farinaceous food is first begun, a teaspoonful 
of the flour rubbed up with milk can be added to the meal of milk thick- 






INFANTILE ATROPHY — TREATMENT. 605 

ened with MeHin's food. Later, the flour can be given with milk as a sep- 
arate meal. 

No beef-tea or broth should be allowed until the baby is at least ten 
months of age. At that time he may begin to take weak beef, veal, or 
mutton broth, and may also have the yolk of an egg lightly boiled, or 
beaten up with milk in the 'bottle. The child may take light pudding at 
the age of twelve months, but no meat for several months longer. 

All changes made in the diet from the earliest period to the latest 
should be made cautiously, and their effect carefully observed. If the 
meal appear to excite indigestion and flatulence, the new food must be 
given on the next occasion in smaller quantity, or we may wait for a week 
before giving it a second time. 

Scrupulous cleanliness, and the purest air attainable, are of great im- 
portance. The child should be washed over the whole body twice a day — 
once with soap. He should wear a flannel binder round the belly. No 
slops or soiled linen should be allowed to remain in the nursery, and the 
window of the room should be kept open as much as is practicable. The 
infant should be taken out of doors for several hours in the day ; and while 
every care is taken to guard his sensitive body against sudden changes of 
temperature, he must not be covered up by too-heavy clothes, and shut off 
from every breath of air for fear of his catching cold. A child ought to lie 
cool at night, and the furniture of his cot, although sufficiently thick to 
insure necessary warmth, should not be cumbersome so as to be a burden. 

The above directions, strictly carried out, will be found to succeed in 
most cases where the child's digestive organs have not been irritated and 
weakened by unsuitable meals. Often, however, the infant only comes un- 
der observation after attempts — more or less injudicious— have been made 
to rear him, and advice is sought because the measures adopted have been 
found to be unsuccessful. Exceptional cases are also sometimes met with, 
where the infant from the first is unable to digest cow's milk. However 
carefully the food may be prepared, each meal either excites vomiting, or 
produces great acidity and flatulence, and the general nutrition of the child 
becomes gradually impaired. 

In every case of milk indigestion, we should inquire carefully as to the 
time of feeding, the quantity supplied at each meal, and the attention be- 
stowed upon cleanliness in the feeding apparatus. 

The inability to digest cow's milk may be a natural peculiarity of the 
infant, or a merely temporary incapacity arising from a disordered state of 
the digestive organs. In the first case, if a wet-nurse cannot be procured, 
or is objected to, we may give the milk of the goat or ass. Either of these 
is usually well digested by children who find cow's milk too heavy. The 
addition of a third or fourth part of barley-water still further increases the 
digestibility of the meal, and Mellin's food may be dissolved in the mixture 
with advantage. Both these milks should be boiled before being used. 
Ass's milk sometimes has laxative properties which boiling will remove. 
By the same means the strong flavour of goat's milk may be diminished, 
although this is often not objected to by the infant. An aromatic, such as 
a couple of teaspoonfuls of cinnamon water, added to the milk, seems often 
to supply a stimulus to digestion ; and I have known infants who were 
invariably troubled with flatulence and discomfort after a meal of plain 
cow's milk and barley-water, digest perfectly the same mixture when thus 
aromatised. If test paper show slight acidity of the milk, a pinch of bi- 
carbonate of soda should be always added to the bottle. 

Condensed milk is often recommended in these cases, and is usually 



606 DISEASE IN CHILDEEN". 

well digested, but the nourishment it supplies is very insufficient for a 
growing baby. The child may get fat, but is usually lethargic and dull. 
Although big, he is not strong ; and unless the milk be largely supplemented 
by Mellin's food, the infant will probably drift into rickets before he is 
seven or eight months old. The same maybe said of the other foods con- 
taining preserved milk, as Nestle's and Oettli's Swiss milk food. They 
are often more easily digested than undiluted cow's milk, but after the 
first few months should not be relied upon to supply the whole nourish- 
ment of the baby. In all cases it is advisable to revert to fresh cow's milk 
as soon as this can be done with safety. There is another reason why an 
infant should not be allowed to derive his whole nourishment from tinned 
and preserved foods. It is now a recognised fact that hand-fed babies 
are liable to a form of scurvy ; and if the child be entirely deprived of 
fresh milk and other anti-scorbutic foods, this consequence of injudicious 
feeding is very likely to be brought about (see page 253). 

It is in cases where ordinary cow's milk is digested with difficulty that 
Dr. Kobert's plan of pancreatising the milk is so valuable. Pancreatised 
milk is prepared in the following way : — To a pint of new cow's milk is 
added half a pint of boiling water, two teaspoonfuls of Benger's pancreatic 
solution, and twenty grains of bicarbonate of soda dissolved in a little 
water. The whole is stirred up in a jug, which is afterwards covered, and 
then placed in a warm situation under a " cosey." At the end of an hour, 
the contents of the jug are emptied into a sauce-pan, and the mixture is 
boiled for two minutes to stop further action of the pancreatine upon the 
milk. The food is then ready for use. It may be sweetened to the child's 
taste with sugar of milk. In milk so prepared, the casein is peptonised by 
the action of the pancreatine, and the main difficulty in the digestion of 
the milk is removed. This method is, in my opinion, far preferable to that 
suggested by Prof. Frankland. In the latter method (artificial human milk), 
the cow's milk is diluted with a third part of whey, and no doubt by this 
means the normal proportion of casein in woman's milk may be exactly 
imitated ; but the process does nothing to render the stiff curd more di- 
gestible, and the firm clotting of the casein is just the difficulty which it is 
so essential to overcome. 

A temporary incapacity for digesting milk on account of gastric de- 
rangement, is a common phenomenon in the young child, and, indeed, is 
the most frequent cause of failure in hand-feeding. If a change be not 
made in a diet which evidently disagrees, it is not long before a catarrh 
of the gastric mucous membrane becomes established. This derange- 
ment, when once confirmed, is not always easy to control, and, if very 
stringent measures are not promptly taken, may lead to the death of the 
child. A mild form of gastric disturbance sufficient to prevent the diges- 
tion of milk, is not unfrequently met with, even in children at the breast. 
It is indicated by a sour smell from the mouth, a slight sallow tinge of the 
skin, and by the vomiting of each meal directly after it has been swallowed. 
Sometimes the bowels are relaxed, from participation of the intestinal 
mucous membrane in the derangement. A condition such as this may 
exist almost from birth. It is a common accident in hand-fed babies, and 
if neglected, leads, as has been said, to serious and perhaps fatal conse- 
quences. 

In children at the breast, the derangement is usually quickly remedied 
by the administration two or three times a day of a few grains of bicarbon- 
ate of soda, and half a drop of the tincture of nux vomica, in a teaspoonful 
of some aromatic water. In infants artificially fed, the disorder is not so 



INFANTILE ATEOPHY — TEEATMEOT. 607 

easily cured, and a complete change in the diet will be required. The 
pancreatised milk is very useful in these cases, and in conjunction with the 
alkaline mixture just referred to, will often quickly restore the digestive 
organs to a healthy condition. If this do not succeed, it will be necessary 
to stop all milk-food for a day or two. The youngest infants bear a tem- 
porary deprivation of milk exceedingly well ; and when, as in the derange- 
ment spoken of, the symptoms are the direct consequence of fermentation 
and acidity, a withdrawal of the fermentable material is followed by im- 
mediate and striking improvement. Even in the most obstinate and pro- 
tracted cases of gastric derangement in young babies, the withholding of 
milk-food, combined with proper measures to support the strength and 
maintain the heat of the body, will be generally successful in restoring the 
infant to health. The same treatment is of equal service in cases of severe 
acute gastric catarrh in hand-fed babies. 

Some time ago I was asked to see an infant two months old, whom I 
found suffering from acute gastric catarrh, and in a state of great exhaustion. 
She had been brought up by hand, and was being fed upon milk and bar- 
ley-water in equal proportions. This she vomited as soon as it had been 
swallowed, bringing it up curdled and intensely acid. There w r as a sour 
smell from the breath, and although the disease had only lasted a few 
days, the eyes were hollow, the face looked pinched, the fontanelle was 
deeply depressed, and she lay motionless on the nurse's lap with her eyes 
half closed. Her hands and feet were cold to the touch and looked purple. 
For a day or two her bowels had been much relaxed. She was taking small 
doses of lead and opium to check the diarrhoea, but each dose was returned 
almost immediately. The child was ordered to be kept warm and perfectly 
quiet. A week mustard poultice was applied for an hour to the epigastrium. 
The milk was stopped, and the child was fed with weak veal broth and thin 
barley-water mixed together in equal proportions, and given cold at inter- 
vals with a teaspoon. A few drops of brandy were also given occasionally, 
as seemed desirable. As a result of this treatment, the vomiting stopped 
at once, and the child when seen three days afterwards was found to be 
greatly improved. The breath had lost its sour smell, the face was no 
longer pinched, the eyes were not hollow, the fontanelle was not depressed, 
and when asleep the child closed her eyelids. The motions were still 
rather watery, although the number was natural. The medicine and diet 
were continued for a few days longer, and the child was soon well 

The most important part of the treatment in this case was the substitu- 
tion of veal broth for milk. Directly the supply of fermentable matter was 
stopped, fermentation ceased, acid was no longer formed, and the digestive 
organs returned to a healthy condition. Here the derangement was acute. 
In the following case the complaint was chronic, the inability to digest 
cow's milk having extended over a lengthened period. 

A little girl, ten months of age, very thin and weakly-looking, had been 
weaned at the age of eight months. Since that time she had been unable 
to digest milk, vomiting it at once whenever it was given to her. For 
nearly two months, therefore, she had been fed on two dessert-spoonfuls 
of farinaceous food made with water into a thick cream, and given every 
two hours with a spoon. She refused to take it from a bottle. Twice a 
day the food was made with beef-tea instead of with water. After a meal 
the child often vomited, but when this happened she was immediately fed 
again. The result of such a diet was to be expected. The child, although 
ten months old, could not sit up. She was becoming rapidly thinner. She 
slept very little, crying and whining the greater part of the night. She was 



608 DISEASE IN CHILD PwETtf. 

said to show no signs of abdominal pain, but the bowels acted three times 
a day, and the motions were relaxed and horribly offensive. The feet were 
almost always cold. 

Such a case, which is far from being an uncommon one, is readily treated, 
however severe may be the vomiting, by restricting the diet to equal parts 
of weak veal broth and thin barley-water, given cold in small quantities at 
a time ; by warmth to the belly and extremities ; by perfect quiet, and by 
suitable remedies. The best sedative is liq. arsenicalis — half a drop for 
the dose — given with a few grains of bicarbonate of soda in some aromatic 
water. It may be sweetened with spirits of chloroform. After a few days 
of such treatment, the power of digesting milk usually returns. But at 
first it should be given sparingly, either pancreatised, or freely diluted with 
barley-water, and only once or twice in the day. If the inability to digest 
milk continue, the case must be treated as described under the head of 
Chronic Diarrhoea (see page 640). 

It may be necessary to begin the treatment by a dose of castor-oil, or 
rhubarb and soda, to clear away undigested food from the bowels. If the 
child is very weak, white wine whey l is very useful. This may be sucked 
from a feeding-bottle, or given with a syringe-feeder, and the infant, if 
feeble, may take it in large quantities. Alternate meals of this whey, and 
of weak veal broth diluted with an equal proportion of thin barley-water, 
forms a very suitable diet for such cases. Mellin's food, dissolved in thin 
barley-water, or plain whey and barley-water, is also very useful ; and a 
dessert-spoonful of fresh cream, shaken up with a teacupful of plain or 
white wine whey, is a very valuable resource in obstinate cases. 

For the treatment of constipation, colic, looseness of the bowels, thrush, 
and the other accidents attendant upon improper feeding and general mis- 
management, the reader is referred to the chapters treating of these special 
subjects. In conclusion, it may again be remarked that success in the arti- 
ficial feeding of infants depends, in the first place, upon the selection of a 
suitable diet ; and in the second, upon extreme watchfulness to detect the 
earliest signs of indigestion and acidity, and to make the necessary changes 
in the food which have been indicated above. Action must be prompt, for 
delay is often fatal. A food must be changed directly it ceases to agree, 
and any symptom of indigestion must be met at once with a suitable 
remedy. A derangement which in the beginning might have been arrested 
without difficulty soon assumes serious proportions, and if allowed to con- 
tinue, will quickly bring a weakly infant to the grave. 

1 To make white wine whey : — Put a breakfastcupful of new milk in a saucepan on 
the fire. When it comes to the boil, add a wineglassful of sound sherry. Then boil 
again for one minute and strain off the curd. Sweeten with white sugar. 



CHAPTER II. 

GASTRIC CATARRH. 

Catarrh of the stomach in early life is a derangement of common occur- 
rence. It is met with in two forms — a febrile and a non-febrile variety. 
A first attack renders the gastric mucous membrane more susceptible 
than before, and predisposes to a second : on this account, the disorder is 
frequently found to recur repeatedly in the same subject, and serious in- 
terference with the child's nutrition may be the consequence. Catarrh of 
the stomach, unaccompanied by fever, is perhaps the commonest derange- 
ment to which children are exposed. It is a perpetual danger to hand-fed 
babies, and forms, indeed, the chief obstacle to the successful rearing of 
infants. The disorder as met with in early infancy has been already de- 
scribed (see Infantile Atrophy). The present chapter treats only of catarrh 
as it affects older children, after the period of infancy has passed by. 

Causation. — In childhood, the mucous membrane is especially liable to 
be affected by chills, but the " cold " does not always- show itself in the 
form of sore-throat or cough. A gastric or intestinal disorder is a famil- 
iar consequence of exposure to changes of temperature, and to this cause 
most cases of the derangement can be attributed. A child who has suf- 
fered from many such attacks, often acquires an extraordinary susceptibility 
to alternations of temperature, and the most trifling chill will be sufficient 
to induce a return of his complaint. In such children, the mere going out 
with cold feet into raw, damp air, is a common cause of a fresh attack. In- 
sufficient clothing is sometimes the sole cause of the derangement. Chil- 
dren whose parents have a foolish objection to flannel, often suffer greatly 
from continued catarrhs. I have known cases where complete loss of ap- 
petite and persistent wasting resulted from this deficiency, and ceased at 
once when proper measures were taken to protect the child's body from 
the cold. 

Certain constitutional states predispose the child to be readily affected 
by chills. In rickets, a susceptibility to catarrh is a marked feature of the 
disease. Pulmonary and gastric catarrhs are of constant occurrence in such 
subjects, and if the disease be present in a severe form, may lead to a rap- 
idly fatal issue. Scrofulous children, again, are very prone to suffer from 
catarrhal disorders, and gastric derangement in them is very common from 
this cause. There is one peculiarity of gastric catarrh, as it occurs in scrof- 
ulous subjects, which is of importance. It is that the complaint is almost 
invariably accompanied with fever. In such children, the recurring attacks 
of pyrexia, lasting from a few days to a week, which are often complained 
of, are cases of the febrile variety of acute gastric catarrh. 

During the second dentition, the trifling febrile disturbance which is 
excited by the passage of the tooth through the gum, may render the child 
very susceptible to chills, and attacks of gastric catarrh at this time are 
very common. 
39 



610 DISEASE IN CHILDREN. 

Besides exposure to cold, irritation of the mucous membrane by un- 
suitable food may be a source of catarrh. In infants, as has been already 
described, this is the cause to which the derangement can be most com- 
monly attributed. In older children, also, gastric catarrh may be pro- 
duced by similar means, and may be set up by excess of rich sauces, fruit, 
or sweets. As in the case of a chill, the susceptibility to suffer from these 
causes may be increased by temporary or constitutional states. During the 
evolution of a tooth, food which would be readily digested at another time, 
is often found to disagree. 

Morbid Anatomy. — A mucous membrane, the seat of catarrh, is injected 
in spots, and a layer of tough mucus covers its surface. In the stomach the 
mucous surface is often found softened ; but this condition, which, under 
the name of gelatinous softening, or gastro-malacia, was at one time re- 
garded as a pathological feature of great importance, and the cause of the 
symptoms which had been observed during life, is now admitted to be a 
mere post-mortem change which has no practical significance. The gastric 
membrane is thickened, and exhibits patches of redness. The stomach 
often contains much mucus, and not unfrequently fermenting food. 

Symjjtoms. — Attacks of gastric catarrh may or may not be accompanied 
by elevation of temperature. The severe acute attack, with high fever, is 
the less common, and is limited, or nearly so, to the subjects of struma. 
The subacute, non-febrile gastric derangement is much more often met 
with. It is milder in character and more quickly subsides : indeed, from 
the slightness of the symptoms by which it is accompanied, the attack may 
pass almost unnoticed, or be spoken of as "liver" or "biliousness." 

In the acute febrile form, the child feels chilly, or even shivers, and then 
becomes very feverish, the temperature rising, perhaps, in the evening of 
the first day or two, to 104°. The patient complains of no pain, but is 
languid and irritable. He has a sallow complexion, and looks dark under 
the eyes, but his general expression is placid, and unless the child is tired 
by exercise, there is none of the pinched, haggard aspect which is so com- 
mon in cases of really serious illness. The appetite is lost, and there is 
some thirst. The tongue is usually furred on the dorsum, but may be 
clean and red at the tip and edges. Vomiting is not common, but may 
occur, although it is rarely distressing. If the catarrh affect the intestinal 
mucous membrane as well as that of the stomach, there is some diarrhoea ; 
otherwise the bowels are confined. Purging, if present, may be accom- 
panied by some pain in the belly, but this, as a rule is insignificant. At 
night the child is often restless, and is disturbed by dreams from which he 
may wake in great terror. During the day, if the catarrh is severe, he is 
generally drowsy, and sits or lies about without wishing to join in the 
sports of his companions. While the attack lasts, nutrition is in abeyance, 
and the flesh and strength manifestly suffer. After a week or ten days, 
the pyrexia, which had been gradually subsiding, disappears ; the appe- 
tite and spirits return, and the patient is convalescent. 

Often the gastric catarrh is accompanied by symptoms pointing to a 
similar condition of other tracts of mucous membrane. The child may suf- 
fer slightly from catarrh of the nose ; the throat may be a little sore ; the 
eyes may be weak and distressed by a strong light, or there may be slight 
cough. Even if the fever is high, delirium is not common, but there is oc- 
casionally some frontal headache. If the catarrh pass along the duodenum 
to the common bile duct, a mild jaundice is noticed. 

In many cases, an attack such as the above passes off, and the child does 
not suffer again from a similar illness. Often, however, the catarrh, instead 



GASTRIC CATARRH — SYMPTOMS. 611 

of occurring in one solitary instance, returns repeatedly at short intervals. 
Cases of recurring gastric catarrh of greater or less severity are far from 
uncommon ; and these attacks, if the intervals between them are short, may 
exercise a very injurious influence upon the health and general development 
of the patient. Children, the subjects of such catarrhs, become pale and 
thin, for their nutrition is being constantly interrupted. By its influence 
upon appetite and digestion, the catarrh checks for a time the introduction 
of nourishment into the system, and nutrition is hardly restored on the 
cessation of the attack when a return of the derangement suspends it again 
as before. In this way the child may become an almost constant sufferer 
from disordered stomach, and his continued ill health and persistent wast- 
ing excite the gravest apprehensions amongst his relatives. Such cases 
are often supposed to be cases of consumption ; and, indeed, if there be any 
inherited chest weakness, long-continued interference with nutrition, such 
as is produced by a frequent recurrence of these attacks, may go far to en- 
courage the tendency to phthisis. 

In the non-febrile variety, the symptoms are much less striking, for, py- 
rexia being absent, the spirits are less depressed and the patient utters no 
complaint. Most children suffer at times from what is called " biliousness." 
For two or three days together they lose their appetite, mope and lie about, 
have a dull, pasty or sallow complexion, and look dark under the eyes. At 
night they sleep badly, and they are restless and irritable in the day. These 
symptoms are produced by a temporary catarrh of the stomach which in- 
terferes for the time with the digestion of food, but passing off, leaves no 
ill consequences behind. When, however, the attacks are frequent, diges- 
tion is weak, even in the intervals of comparative health, and nutrition be- 
comes seriously impaired. Such children complain often of flatulent pains 
in the sides, and may be subject to attacks of syncope from pressure up- 
wards of the distended stomach against the heart. Their bowels are usually 
costive. The appetite varies greatly. Sometimes it is excessively keen ; 
at others it is poor and capricious. In many cases, indeed, the child seems 
to have no appetite at all, and the greatest difficulty is experienced in mak- 
ing him swallow his food. 

These symptoms may be greatly aggravated by an unsuitable dietary. 
If a child who suffers from the condition described be supplied with an ex- 
cess of fermentable food, such as potatoes, puddings, jams, and sweet cakes, 
he is kept in a state of chronic acid dyspepsia which is a source of constant 
discomfort to himself and anxiety to his friends. The whole system being 
full of acid generated by fermenting food, the child is wayward and cross 
in temper, and excessively fidgety and restless. His speech is often hesi- 
tating, and he may stammer in his talk. His muscles are irritable and 
twitch easily, so that he winks his eyes and distorts in nervous fashion the 
corners of his mouth. The so-called nervous habits of children often owe 
their origin to this derangement. 

Sickness is not a common symptom in these cases, for gastric catarrh is 
by no means always accompanied by irritability of stomach. Sometimes, 
however, the child at rare intervals brings up a large quantity of sour-smell- 
ing fluid and mucus. Frontal headache, more or less severe, is rarely ab- 
sent, and oftentimes the pain is distressing. The wearing periodical head- 
aches of children are not uncommonly owing to this cause. The urine is 
noticed from time to time to be thick with lithates ; and, in rare cases, quan- 
tities of fine uric acid sand are passed, precipitated by the free acid with 
which the urine is charged. 

In some cases a curious condition of the tongue is noticed. On the 



612 DISEASE IK CHILDREN. 

dorsum are seen rounded or oval patches, which appear to consist in a re- 
moval of the epithelial covering. The surface of the patches is distinctly 
depressed, and the colour is that of the dorsum generally. ^ The edges are 
circumscribed and irregular. The number of these patches is usually three 
or four. They may be seated on the dorsum or on the edges of the tongue. 
At times, small rounded ulcers (aphthse) and red elevated papillae are seen at 
the tip of the tongue in addition to the depressed patches on the dorsum. 
If aphtha are not present, there is no pain or soreness. 

Symptoms such as the above show a high degree of digestive derange- 
ment, aggravated by an unsuitable dietary, and are almost invariably the 
consequence of repeated attacks of catarrh of the stomach. Under such 
circumstances, nutrition is interfered with, the child wastes perceptibly, and 
the apprehensions of the parents are carried to a high degree. "When, on 
the other hand, the indisposition is only occasional, and the symptoms are 
not severe, little attention is excited. The child is supposed to be a bilious 
subject, and unless the attacks become so frequent as to cause an evident 
diminution in bulk, or some new symptom is noticed which excites the 
alarm of the friends, medical advice is considered unnecessary. 

In cases where, owing to the mildness or infrequency of the attacks of 
gastric derangement, general nutrition has not suffered, the occurrence of 
fainting fits may induce the parents to apply for medical assistance. At- 
tacks of syncope, more or less complete, are not uncommon in these cases. 
Naturally enough, they give rise to great anxiety, especially if conjoined 
with palpitations and flatulent pains about the chest. They are then con- 
sidered to be symptomatic of heart disease. Thus, a little girl, aged 
eleven years and a half," fainted for the first time six years ago. She has 
since fainted on five different occasions. At these times she has always 
been noticed to be dull and languid, with a poor appetite, but otherwise 
has seemed to be well. Is subject to sharp pains in the left hypochon- 
drium, under the influence of which her face will become ghastly white. 
She sleeps badly, talking and moaning, and often lies awake at night. Has 
never suffered from worms ; bowels are confined. Has sometimes a sallow 
complexion." This young lady, who was a well-grown, well-nourished girl, 
with perfectly sound organs, soon lost all her symptoms under suitable 
treatment. 

In some cases, the non-febrile form of the complaint is accompanied by 
more serious symptoms. There may be severe pain in the epigastrium, 
violent headache, and distressing retching and vomiting, first of food and 
afterwards of bilious or watery fluid. Such attacks are usually soon over. 
They are commonly produced by the introduction of some irritant into the 
stomach, and cease soon after the complete ejection of the offending mat- 
ters from the body. For some days afterwards the child is languid, his 
digestion weak, and vomiting is easily excited. 

In children of eight or nine years of age or upwards, the dyspepsia in- 
duced by repeated attacks of gastric catarrh may give rise to more or less 
severe pain after food, a tendency to vomit, pyrosis, and other symptoms 
such as accompany the derangement in the adult. These symptoms are 
seldom met with except in children who are habitually over-fed, or are in- 
dulged with rich sauces and highly-spiced and stimulating food. They 
usually quickly subside under a change of diet. 

Diagnosis. — The febrile form of acute gastric catarrh often presents 
some difficulty in the diagnosis, for the symptoms are frequently indefinite, 
and the case may be mistaken for one of far more serious disease. Such 
cases have been confounded with cases of acute tuberculosis, and they often 



GASTRIC CATARRH — DIAGNOSIS. 613 

preseDt a strong likeness to the mild form of enteric fever. The prin- 
cipal points upon which the diagnosis is founded will be best illustrated 
by the narration of the following case seen in consultation with Dr. 
G nther. 

A little girl, aged seven years, of a strumous disposition, had been deli- 
cate and subject to occasional failure of appetite for some months. For 
about a week she had been feverish, the bodily temperature rising some- 
times as high as 104° Fahr. Her appetite had been completely lost, but 
she had not suffered from sickness. The bowels, at first sluggish, had been 
somewhat relaxed for two days, the motions passed being moderate in quan- 
tity, but loose, rather offensive, and bright yellow in colour. She had oc- 
casionally complained of abdominal pains. During the whole time of her 
illness the child had snuffled slightly, and at first her throat had been a 
little sore, but there had been no cough. She had complained sometimes 
of frontal headache, but had not been delirious. 

At my visit I found the child lying in bed with her face turned away 
from the window, as the light, she said, hurt her eyes. There was no sal- 
lowness of complexion. Her expression was placid, and not at all anxious or 
distressed. The tongue was a little furred on the dorsum, and rather red 
at the tip and edges. She was thirsty, but had no desire for food. The 
abdomen was soft, without tenderness or distention. The spleen was very 
indistinctly felt ; it seemed to be slightly enlarged. There was no rash of 
any kind on the body, nor any oedema of the legs. The urine was not al- 
b iminous. The heart sounds were healthy. There was no rhonchus, nor 
any other abnormal sign about the lungs. Respiration regular, 24 ; pulse 
regular, 108 ; temperature, 101° (at 4 p.m.). 

This case, which was seen on the seventh or eighth day of the illness, 
when the ordinary eruptive fevers could be excluded, might have been 
acute tuberculosis, typhoid fever, or acute gastric catarrh. The occur- 
rence of fever, with a history of previous delicacy of health, was quite in 
keeping with the ordinary course of tuberculosis. There was, however, no 
family history of any such complaint, and this important fact, together with 
the complete absence of distress or anxiety in the expression of the child, 
and the absence also of any oedema of the extremities, was held sufficient 
evidence to exclude the presence of this formidable disease. 

Between typhoid fever and acute gastric catarrh the distinction was 
more difficult. The temperature, it is true, although always elevated, had 
not followed the course of the temperature in a typical case of enteric 
fever ; but in children this fever is often mild, and frequently deviates from 
the ordinary type. Again, the absence of eruption did not exclude typhoid 
fever, for the eighth day is early for the rash to appear, and in children ty- 
phoid spots are sometimes absent altogether in undoubted cases of the dis- 
ease. On the other hand, the state of the spleen was doubtful. Some 
slight enlargement was suspected ; if this was so, the fact pointed distinctly 
to typhoid fever. 

In favour of acute gastric catarrh was the slight snuffling, the mild sore 
throat, the complete absence of delirium or of apparent discomfort, and 
the irregularity of the fever. Altogether, the symptoms pointed, perhaps, 
more decidedly to gastric catarrh than to the more serious disease, but it 
was impossible to exclude typhoid fever ; therefore, a guarded opinion was 
expressed as to the nature of the case. The temperature fell on the follow- 
ing (eighth or ninth) day. This early termination seemed to decide the 
question in favour of catarrh, for it is only in very exceptional cases that 
typhoid fever subsides before the fourteenth day. 



614 DISEASE IN CHILDPwEN. 

When gastric catarrh, instead of occurring in one solitary attack, as in 
the above instance, recurs repeatedly at short intervals, the diagnosis is 
more easy. This recurrent form is well illustrated by the following case 
which was sent to me by Dr. Lister, of Croydon. 

A little girl, aged seven years, pallid in appearance and ill-grown, had 
been wasting slowly for eighteen months. During the whole of this time 
she had suffered every two or three weeks from attacks of feverishness. In 
these illnesses the symptoms were the same. The temperature rose to 103 J 
and 104°. The child looked sallow in the face, and was very irritable and 
languid. She was thirsty, but refused her food. Sometimes she vomited, 
but in the earlier attacks the bowels were never relaxed; She got thinner 
and weaker, and looked ill. A few months previously she had had a severe 
attack at Lowestoft, in which she had been slightly jaundiced. Six weeks 
before her visit to me she had had a still more violent attack, which had 
left her completely jaundiced. This had been followed for the first time in 
her experience by diarrhoea ; and for a fortnight the motions were green 
and slimy, and sometimes contained clots of blood. They were passed 
with straining and some pain. At the time of her visit, the looseness had 
in a great measure subsided, but the child still had a faint yellow tint of 
the skin. Her heart and lungs were healthy, and there was no sign of en- 
largement of the bronchial glands. Between the attacks of illness the 
child was said, as a rule, to be fairly well. On the subsidence of the fever 
her appetite would return, and she would begin to regain flesh. Unfortu- 
nately, before her strength could be said to be thoroughly restored, it would 
be again reduced by a new access of fever. 

Jaundice in children after the period of infancy, is, in the large majority 
of cases, catarrhal. In this child, its occurrence with the two last attacks of 
fever helped greatly to explain the nature of these attacks, and the cause 
of the ill-health from which the child was suffering. Moreover, in the 
most recent illness, a new feature had been noticed in the diarrhoea which 
had followed the jaundice and still further delayed convalescence. In this 
diarrhoea, the characters of the stools, which contained mucus and blood, and 
were passed with straining and pain, pointed to a catarrh of the lower 
bowel. Explaining, then, the earlier attacks in the light afforded by the 
latter, it was evident that the child's sensitiveness to changes of temperature 
showed itself in the form of repeated attacks of acute gastric catarrh, ac- 
companied by fever. This fact being once established, the treatment of 
the case was conducted upon the principles to be described, and the child 
had no return of her feverish symptoms. 

The non-febrile form of the disease may be recognised without difficulty. 
Frequently-recurring attacks of indigestion, a tendency to acidity and flat- 
ulence, restlessness and irritability after indulgence in sweets and other 
forms of fermentable food, are almost invariably the consequence of gastric 
catarrh. The complaint is so common a one that it should be always sus- 
pected in children who are habitually pale, thin, and nervous, with a sallow 
complexion, and who are subject periodically to fits of irritability and ill- 
temper. Continued loss of appetite from this cause often excites appre- 
hensions that the child is becoming consumptive. The real cause of his 
wasting may, hoewver, be detected by noticing that the chest, on examina- 
tion, shows no sign of disease ; that his expression, although occasionally 
wearied, as after exertion or before going to bed, is not habitually distressed, 
and that the evening temperature is normal. On inquiry, too, it will be 
found that the wasting is not a constant feature, but that the child is 
better and worse, sometimes appearing to be almost well and to gain flesh ; 



GASTRIC CATARRH — TREATMENT. 615 

at others, being languid, moping, and sallow-looking when indigestion is 
excited by a fresh attack of catarrh. 

Treatment. — Whether the gastric catarrh assumes the febrile or the non- 
febrile form, its treatment is the same. Our object is, firstly, to put a stop 
to the existing derangement, and, secondly, to adopt such measures as will 
prevent its recurrence. 

To cure the existing catarrh, we must do our best to remove all sources 
of irritation which may be keeping up the disorder. The acrid mucus, a 
free secretion of which is one of the ordinary phenomena of the catarrhal 
state, is a constant source of fermentation and acidity. It very quickly in- 
duces an acid change in the more fermentable articles of food. Therefore, 
if the stomach be oppressed by sour matters, shown by uneasiness at the 
epigastrium, a sour smell from the breath, and a feeling of nausea, im- 
mediate benefit will be derived from an emetic dose of ipecacuanha wine. 
Afterwards, a draught composed of tincture of nux vomica (TT[j.-iij.), with 
bicarbonate of soda (gr. iv.-vi.), in water sweetened with spirits of chloro- 
form, taken two or three times a day, will soon restore the gastric mucous 
membrane to a healthy condition. Strong purgatives are to be avoided, 
but as there is usually constipation in these cases, an occasional mild ape- 
rient will be required, such as compound liquorice powder or castor-oil. If 
there be fever which does not subside after the action of the emetic, the 
child may be allowed to take fluids from time to time in moderate quanti- 
ties. The best are unsweetened barley-water, flavoured, if desired, with 
orange-flower-water, and fresh whey. 

During the treatment, as long as any signs of acidity of the stomach 
persist, care should be taken to exclude from the diet all matters capable 
of favouring the tendency to fermentation of food ; and even for some time 
afterwards, readily fermentable substances, such as starches and sweets, 
should be taken sparingly, lest the derangement be encouraged to return. 
At first, nothing should be allowed but freshly-made broths, with dry toast, 
and when milk is once more permitted, it must be guarded with a fourth 
part of lime-water, or with saccharated solution of lime, in the proportion 
of twenty drops to the teacupful. While the derangement continues, no 
fruit, cake, sweets, light puddings, or potatoes should be permitted. When 
the appetite begins to return, a little fish, chicken, or mutton may be al- 
lowed, but the child must not be pressed to eat ; indeed, until his diges- 
tive power be completely restored, the utmost care must be taken not to 
overload the stomach with food. 

The above measures will effect a considerable improvement in the con- 
dition of the child, but at this point the treatment may be said only to have 
begun. The patient is in a weakly state from successive attacks of gastric 
catarrh. We have therefore to adopt measures to strengthen the diges- 
tive power, and take such precautions as will insure him against a relapse. 

To give tone to the stomach and strengthen digestive power, prepara- 
tions of iron are required. It is a common practice in such cases to admin- 
ister the preparation of the phosphates of iron and lime known as " Par- 
rish's chemical food." This syrup is a very favourite remedy with mothers, 
who, misled, perhaps, by the name, give it largely, and with the worst results. 
Theoretically, no doubt, it is an active tonic, but practically it is highly per- 
nicious. The reason is that the syrup in which the phosphates are dissolved 
supplies material for fermentation, and each dose is soon followed by acid- 
ity and flatulence, so that the medicine really aggravates the mischief it is 
intended to allay. The better plan is to give the dialysed iron, or, if there 
be any tendency to acidity remaining, the ammonio-citrate, with a few 



616 DISEASE IN CHILDEEN. 

grains of bicarbonate of soda, sweetened with spirits of chloroform. After 
a time a change may be made to the solution of strychnia, with the per- 
chloride orpernitrate of iron, given directly after food. All this time, the 
quantity of fermentable material taken at meals much be restricted, as al- 
ready recommended. During the same time, a mild aperient should 
be given every few days, whether it seems to be required or not, to 
insure proper relief to the bowels, and prevent the retention of any excess 
of mucous secretion. 

In spite of this treatment, however, the child will not be secure against 
relapses unless special precautions are taken to guard the body against 
chills. The catarrhal state, whatever be the organ affected, tends con- 
stantly to repeat itself under the influence of slight causes, and there is 
little doubt that it induces an extreme sensitiveness to changes of tempera- 
ture. Children who suffer from attacks of catarrh of the stomach and 
bowels, should wear a broad flannel bandage applied tightly to the ab- 
domen, so as to reach from the hips upwards to the arm-pits ; and the 
medical practitioner should look upon it as his first duty in these cases to 
see that it is properly applied. The binder should be considered as part 
of the child's ordinary dress, and be cast off at night with the rest of his 
clothes. In many cases it is necessary, in addition to the above precautions, 
to fortify the resisting power of the child by cold bathing. Some caution, 
however, is often required in recommending this step to parents. Mothers 
are apt to take fright at the very mention of cold water ; and it is true that, 
in the case of weakly children, reaction is difficult to establish, so that a cold 
bath given in the ordinary way would not be attended with benefit. If, 
however, the bath be given according to the method advocated on a pre- 
vious page (see page 17), and the skin be first stimulated by vigorous fric- 
tion so as to enable the body to resist the shock of the cold douche, and 
the shock itself be lessened by making the child sit in a few inches of hot 
water, the bath will have a highly invigorating effect and be followed by 
immediate reaction. The continued use of this bath, besides having a re- 
markably tonic effect upon the system generally, confers great resisting 
power against changes of temperature, and considerably reduces the child's 
susceptibility to chills. 

By means such as have been indicated, the most obstinate gastric catarrh 
may be treated with success. But it must be borne in mind that success 
depends upon equal attention to all the points that have been insisted 
upon. A flannel binder will be of little value if the tendency to fermenta- 
tion is encouraged by the immoderate use of starches and sweets ; and even 
cold douching may not be sufficient to neutralise the ill-effects of rapid 
changes of temperature acting upon a body imperfectly protected from the 
cold. In all cases, it is advisable to avoid the use of syrups in making 
medicines palatable to children. The pharmacopoeia syrups are not well 
borne by young subjects, and often do more harm than good. It is far 
better to sweeten the child's physic with glycerine, or a few drops of spirits 
of chloroform. 

In cases where habitual pain after food is complained of, the treatment 
found useful in similar cases in the adult should be resorted to. The diet 
should be arranged on the principles already "indicated. Both sauces and 
highly-spiced or fermentable food should be forbidden, and the child 
should take bismuth and soda, or small doses of dilute hydrocyanic acid 
with an alkali. 



CIIAPTEE HI. 

CONSTIPATION. 

Childken of all ages are subject to constipation. Usually, it is a temporary 
derangement, which quickly subsides under suitable treatment. In other 
cases it amounts to a positive infirmity, and is exceedingly obstinate and 
difficult of cure. The term constipation is a relative one. In itself, it im- 
plies injury to the health from retention in the alimentary canal of matters 
which ought to be discharged. The condition is therefore compatible with 
a daily evacuation, if the relief afforded to the system is incomplete. In 
infants who require the bowels to be emptied several times in the day, a 
single stool in the twenty-four hours is a sign of costiveness which should 
not be neglected. 

All forms of mechanical obstruction to the passage of the intestinal con- 
tents give rise to arrested or imperfect evacuation as a prominent symptom. 
This variety of constipation is not here referred to. The form under con- 
sideration in this chapter is due to deficiency of expulsive action, and not 
to narrowing of the channel, or other kind of mechanical hindrance. 

Causation. — One of the commonest causes of constipation is an unsuit- 
able dietary. This is especially the case in infants. A child brought up 
by hand, and fed with excess of farinaceous food, is often troubled with an 
obstinate form of costiveness which is a source of continual discomfort. 
The frequent passage along the bowels of undigested starchy matter keeps 
the mucous membrane in a state of constant hyper-secretion. A slimy mu- 
cus is thrown out which coats the lumps of undigested food so that the 
muscular coat of the bowel in its contractions can have little hold upon 
their slippery surface, and they are forced forwards with difficulty. 

Still, all cases of constipation occurring in hand-fed babies cannot be 
attributed to this cause. Often, the most careful examination of the stools 
can detect no excess of mucus. On the contrary, the motions are hard and 
lumpy, and seem to be drier than natural. This very dryness of the evacu- 
ations appears in many cases to constitute, a cause of infrequent relief to 
the bowels. We know from cases of diabetes in the adult, where the ex- 
cessive drain of water from the kidneys diminishes intestinal secretion, how 
commonly constipation results from this want of moisture. In the young 
child, a similar deficiency of secretion, however induced, may cause dryness 
of the fsecal contents and diminish the facility of their passage. Special 
articles of diet have a constipating effect upon certain children. In some, 
rice interferes with the regular action of the bowels. In others, eggs may 
induce a like sluggishness. I have known troublesome costiveness continue 
as long as the yolk of an egg was allowed every day, and disappear at once 
when the number of eggs was reduced to two in the week. 

Atony of the bowel, or actual deficiency of expulsive power, is a not un- 
common cause of constipation even in young subjects. In badly-nourished 
children, the muscular coat of the intestine must share in the general mal- 



618 DISEASE IN CHILDREN. 

nutrition; and as, in this condition, the lower part of the colon and rectum 
are apt to be over-distended by accumulation of undigested food, the diffi- 
culty of carrying forwards the fsecal masses is increased. In some cases, the 
difficulty is added to by a peculiarity of infancy upon which Dr. Jacobi has 
laid much stress as a cause of constipation in very early life. In the new- 
born infant, the length of the large gut is proportionately greater by about 
one-third than it is in the adult. This excess of length is due, not to the 
ascending and transverse colon, which are rather shorter at this age than 
the}' become in after years, but to the descending colon and sigmoid flexure. 
Consequently, the flexure is thrown into many curves, and is often bent 
upon itself so repeatedly as seriously to retard the passage of its contents. 

Sluggishness of peristaltic action, if not complete atony of the bowel, 
may be a sequence of certain diseases. After chronic diarrhoea, a state of 
constipation commonly prevails which is very difficult of cure. Typhoid 
fever often leaves a similar condition behind it, and after an attack of acute 
rheumatism the same inactivity of the bowels is often noticed. Again, ul- 
ceration of the intestinal mucous membrane, when not accompanied by ca- 
tarrh, almost invariably induces deficient fsecal excretion, and sometimes, in 
these cases, excrementitial matters may be long retained. In typhoid fever, 
constipation of a week or longer is frequently met with, and indeed, in many 
cases, no effort at expulsion appears to be made until the bowels are excited 
to contract by a copious enema. In these cases, no doubt, the normal pe- 
ristaltic action of the bowels at the seat of ulceration is paralysed by the 
inflammatory process there existing ; but a similar sluggishness of the in- 
testinal mucous membrane may be induced by disease in a distant part of 
the body. Thus, disease of the brain or its membranes is usually accom- 
panied by constipation as a prominent symptom, and in another part of 
this volume reasons are given for supposing that Bright s disease in the 
young child may produce the same result. 

There is one cause of constipation in infants which must not be for- 
gotten. This is the sluggishness of the bowels which is induced by opium. 
Hand-fed babies are apt to be very peevish and troublesome at night, and 
an unscrupulous nurse will often drug the child with " soothing syrup " or 
other opiate in order that her own sleep may be undisturbed. This prac- 
tice induces a very obstinate form of constipation, and, unless detected, may 
be a cause of much perplexity to the medical attendant. It is therefore 
important in obstinate cases to examine the child's pupils. 

The causes which have been referred to may influence the state of the 
bowels at all periods of childhood, but there are other causes which largely 
prevail after the period of infancy has passed. Habitual neglect of the 
calls of nature is as common a cause of constipation in young people as it 
is in their elders. The lower bowel, when it finds its warnings neglected, 
soon becomes accustomed to the presence of its fsecal contents, and requires 
something more than the ordinary stimulus to excite its action. Whether 
from necessity or convenience, school-children of both sexes often suppress 
the natural desire for relief ; but if the favourable moment is allowed to 
pass, efforts made at another time are often ineffectual, and a habit of con- 
stipation is thus acquired which may be very difficult to overcome. Even 
during infancy, constipation may be made worse by this means. Children 
of ten or twelve months old, who have been subjected to much pain from 
distention of the sphincter by hard fsecal masses, will often resist, as long 
as possible, the desire to empty the bowel, in order to spare themselves un- 
necessary suffering. In such cases, if measures are not taken to enforce due 
evacuation, serious accumulation may ensue. 



CONSTIPATION — SYMPTOMS. 619 

Want of exercise is another cause which is often found to prevail 
amongst young girls, especially if they are much confined to the house and 
pressed too quickly forward in their studies, and very obstinate constipation 
may result from their sedentary life. 

Symptoms. — In infancy, deficient excretion from the bowels is usually 
indicated by a pasty, dull complexion, fretf illness, and agitation, especially 
at night. The child's sleep is not the sound, unbroken sleep of health. He 
often starts and twitches, and is roused up by the least noise. Flatulence 
is an early consequence. The child seems to suffer from occasional twinges 
of pain, for he often cries suddenly without evident cause, and draws up his 
lower limbs uneasily. His upper lip looks purple ; the muscles of his mouth 
twitch, and if the pain is severe, his whole complexion may become ghastly 
white. If the constipation is obstinate, the stools are voided with great diffi- 
culty ; and in cases where several days pass without any relief, defecation is 
only effected with much straining and pain. The infant often makes violent 
efforts to unload his bowel of its accumulated burden, and will strain until 
his face is purple, his bowel prolapses, and his navel starts. Tinging of the 
fecal masses with blood from rupture of small vessels about the anus is often 
seen, and umbilical hernia not unfrequently owes its origin to this cause. 

The belly is generally swollen from flatulence, and sometimes the gas 
accumulates in such quantity as to cause a fit of violent colic, in which the 
child gives signs of extreme suffering, screaming and writhing and draw- 
ing up his legs. Actual convulsions may be induced by this cause. In 
cases where irritation of the bowels is excited by the retention of excremen- 
titial matters, the temperature may become elevated for a time, but it sub- 
sides at once when the accumulation has been removed. In many children, 
the torpor of the bowel is accompanied by languid circulation, so that* the 
hands and feet are habitually cold. If the state of constipation continue, 
the general health usually suffers ; the flesh gets flabby, and the child is 
peevish and fretful, with a tendency to vomit. Palpation of the abdomen will 
often discover hard masses in the descending colon. These are well-defined 
lumps, are painless, and can be indented by firm pressure with the finger. 

In older children, we see little more than dulness of complexion, a furred 
tongue, and some want of sprightliness and activity. The child may com- 
plain of discomfort after food and of occasional headaches. His breath is 
often unpleasant, and there may be aphthae on the tongue and lips, or red 
patches on the tongue from which the epithelium appears to have been 
thrown off. Sometimes the bowels act only at rare intervals, and if proper 
measures are not resorted to, may remain confined for a week together, or 
even longer. Such children are subject to sick-headaches, and have habit- 
ually a pasty -looking, unhealthy tint of skin. 

If the constipation proceed to actual impaction of faecal masses in the 
bowel, more striking symptoms are noticed. The impaction usually takes 
place in the rectum itself, and consists of a quantity of hard lumps which 
it is very difficult to break down and bring away. The presence of the 
hard masses causes irritation, which shows itself by more or less pain in 
the lower part of the belly, by tenesmus, and often by difficulty of micturi- 
tion. The child is generally sallow, listless, and weakly-looking. The appe- 
tite may be unaltered, but is usually poor. The tongue is often quite clean, 
although the breath is foetid. The belly is distended and sometimes tender. 
Diarrhoea may be a consequence of the intestinal irritation. The motions 
are scanty and thin ; they usually contain a few small scybala, and are 
passed with much pain and tenesmus. Instead of loose, they may be very 
small and solid, with excess of mucus. 



620 DISEASE IN CHILDREN. 

In some cases, in addition to irritation, positive injury may be caused by 
ihe presence of the faecal masses. Dr. T. Chambers has reported the case 
of a girl, aged eleven years, who had suffered for three months from a per- 
sistent diarrhoea which was the consequence of a vast accumulation of faeces 
in the rectum. The mass by its pressure had caused absorption of the 
triangular cushion which constitutes the perinaeum, and had reduced the 
recto-vaginal septum to a mere membrane. 

These cases, if not judiciously treated, may actually prove fatal. Dr. 
Bristowe has referred to the case of a little girl, eight years old, who had 
long suffered from a tendency to constipation, and had occasionally gone for 
three weeks without relief to the bowels. When she came under observa- 
tion she had had no passage for seven weeks. The child was pale and thin, 
with a strumous look. Her belly was large and tense, although painless, 
her tongue clean and her appetite poor. She grew weaker, and looked hag- 
gard and anxious. Her belly became more distended, and occasional colicky 
pains were complained of. Towards the end, her tongue became foul ; she 
often vomited, passed high-coloured urine in small quantity, and eventually 
sank from exhaustion. The vomiting was never stercoraceous. After death, 
the intestines were found greatly distended and their coats hypertrophied. 
They were full of olive-green, semi-solid faeces, which were of thicker con- 
sistence in the rectum than elsewhere ; and immediately above the anus 
was a hard conical plug of faecal matter which completely prevented the 
escape of the contents of the bowel. 

If impaction take place at a higher point in the bowel — in the caecum 
or at a bend of the colon — symptoms of complete occlusion may arise, 
and inflammation is often excited in the intestine. Over the seat of ob- 
struction there is pain, which may extend to the whole abdomen, and be 
violent and paroxysmal ; there is tenesmus, and the bowels are obstinately 
confined. The child vomits repeatedly, throwing up at first bile and mu- 
cus, afterwards feculent matter. Hiccough may be distressing. The abdo- 
men is distended. The tongue is thickly furred, and perhaps dry and 
brown. The pulse is rapid, small, and thready ; the temperature is often 
high, and the prostration is extreme. On examination of the belly, a hard 
swelling may be detected through the muscular wall, and can often be 
indented with the finger ; or, if inflammation have occurred, there is some 
tension of the parietes, and an intensely tender swelling can be discovered 
at the seat of obstruction. Inflammation of the caecum (typhlitis) is the 
most familiar instance of this inflammatory form of the disorder. Firm 
impaction of the colon with faeces is a variety of obstruction which, if not 
relieved by the adoption of suitable measures, may be as fatal to the pa- 
tient as any other form of intestinal occlusion, but it is eminently cura- 
ble if the nature of the impediment be recognised in time. 

Diagnosis. — In ordinary cases, the want of regularity in defecation, and 
the infrequent passage of hard, scanty stools, is a sufficient token of the ex- 
istence of constipation. But often the indications are much less precise. 
In infancy, as has already been remarked, a single stool in the four-and- 
twenty hours constitutes a state of constipation which requires attention. 
Even in older children a daily evacuation may occur and yet the relief to 
the bowels be incomplete. Habitual sallowness of complexion, offensive 
breath, wakefulness at night and startings in sleep, are common indica- 
tions of a loaded bowel, especially if the symptoms occur in a well-nourished 
child who presents no other indication of ill-health ; and dyspeptic symptoms 
(discomfort and a feeling of heaviness after meals, occasional nausea and a 
furred tongue) will often be found to arise from the same condition. 



CONSTIPATION — DIAGNOSIS — TREATMENT. 621 

It is very important in cases where the evacuations are very small, fre- 
quent, and watery, or loose, to remember that this condition is often a 
consequence of the accumulation of faecal masses in the rectum. In 
such cases, we may expect to find distention of the belly and tenesmus, 
with some pain in the lower bowel in defecation ; and the stools, on inspec- 
tion, will be found to consist of offensive, thin feculent matter containing 
mucus and a few small, hard scybalae. When these symptoms are noticed 
in a child of four or five years of age or upwards, it is of importance to 
examine the rectum ; and often by this means the cause of the apparent 
looseness may be discovered at once. Still, even if we obtain evidence of 
faecal accumulation, caution is often necessary. We must not at once con- 
clude that retained faecal matter constitutes the whole of the derangement, 
and that when this has been removed the child will be well. Ulceration of 
the bowels is often accompanied by this \ery group of symptoms. This 
subject is considered elsewhere (see page 661). 

If actual impaction of faeces occur so as to offer an insuperable obstacle 
at any point of the intestinal canal, symptoms of occlusion of the bowel 
arise. The distinction between this condition and intussusception is ex- 
plained in the chapter treating of the latter subject. 

Treatment. — The regular action of the bowels is at all ages so much a 
matter of habit that the child as soon as he can walk, or even earlier, 
should be trained to regularity in this important particular. Every morn- 
ing after breakfast he should be accustomed to go punctually to stool, and 
nothing should be allowed to interfere with this necessary duty. By this 
means the bowels become accustomed to regular relief at the same period 
of the day. The mother should herself see that the rule is enforced, for an 
inattentive nurse, from ignorance or carelessness, is very apt to neglect it. 

In infants, constipation may be combated by careful regimen, by the 
adoption of special articles of diet, by enemata, and by drugs. In the first 
place, the dietary should be revised and excess of starchy matter excluded. 
If the child is eight or ten months old, the first meal in the day may con- 
sist of a teaspoonful of fine oatmeal rubbed up carefully with cold milk 
into a thin, smooth paste, and then stirred briskly while hot milk is added. 
Mellin's "Food for Infants," probably on account of the glucose it contains, 
often has an admirable effect in regulating the bowels of infants who are 
inclined to costiveness, and is a very useful resource. If the constipation 
is only temporary and occasional, a small lump of manna dissolved in a 
dessert-spoonful of warm water, strained and added to the bottle of food, 
has a ready aperient effect ; or fifteen to twenty drops of the liquid extract 
of rhamnus fraugula will be equally successful. In cases where the consti- 
pation is habitual, I have found a combination of the infusions of senna 
and gentian a remedy of unfailing usefulness. I usually combine these with 
the tinctures of belladonna and nux vomica, as in the following draught. The 
quantity ordered is suitable to a child between eight and twelve months of age, 
and can be given at first three times in the day immediately before a meal : — 

J£ . Tinct. nucis vomicae TT[ ss. 

Tinct. belladonna 1U v. 

Infusi sennae • • % xx - 

Infusum gentianse comp ad. 5 j. 

M. Ft. haustus. 

The value of this remedy consists in the fact that the patient does not be- 
come dependent upon the medicine. On the contrary, it has a strength- 
ening effect upon the coats of the bowel, so that after a time it can be given 
twice in the day, then only once, and eventually be discontinued altogether. 



622 DISEASE IN CHILDREN. 

The extract of malt, on account of its glucose, is also useful in relieving 
the constipation of infants ; but must be given in sufficient quantity, i.e., a 
teaspoonful two or three times a day. It is, however, very inferior to the 
senna mixture, and has the disadvantage that in warm weather it is apt to 
turn acid on the stomach and cause nausea. In all cases of habitual con- 
stipation in infants, the belly should be rubbed firmly with the hand twice 
a day after the bath, so as to stimulate the peristaltic movement of the bow- 
els. In obstinate cases, Dr. Merriman advises the friction to be made with 
a liniment composed of half an ounce of the tincture of aloes to one ounce 
of the compound soap liniment. Professor Stephenson, in an interesting 
paper, has proposed the use of pepsin, in cases of habitual constipation, for 
children of all ages. To a child of twelve months old, three grains of the 
dry powder, or five drops of pepsin wine may be given three times a day. The 
remedy must be taken for several weeks, and can then be gradually discon- 
tinued. If necessary, an occasional dose of castor-oil can be given during 
the first few days of taking the pepsin, but this is seldom required to be 
repeated more than twice. 

The above methods of treatment are greatly to be preferred in cases of 
habitual constipation to the mechanical relief of the bowels obtained by 
means of enemata, or even by the use of suppositories. Suppositories of Cas- 
tile soap, cocoa butter, or brown gelatine have been strongly advocated by 
some writers. They are no doubt useful in producing an immediate effect, 
but have no further influence, and cannot promote healthy and regular 
action in the future. Enemata are of service in unloading the bowels where 
there is accumulation of fsecal matter, especially where irritation and colic 
have been excited by its retention. They should be composed of thin gruel 
or soap and water, should be used warm, and if the constipation be obstinate 
or the pain severe, may contain the addition of a spoonful of castor-oil. 
Care should be taken to use a sufficient quantity of fluid. An enema to be 
effectual in such a case should consist of at least two-thirds of a pint for a 
child of six months old. If enemata are given daily to relieve habitual con- 
stipation, the quantity need not be so considerable. Four or five ounces 
will usually be sufficient, and plain water of the temperature of 60° Fahr. 
may be employed. This daily repetition of enemata is not, however, apian 
of treatment to be recommended. 

In the case of severe colic in a baby, flannels wrung out of hot water 
should be applied to the belly, and a copious injection of warm soap and 
water, with or without the addition of a teaspoonful of castor-oil, should 
be administered without delay. If the infant seem depressed as a conse- 
quence of the pain, he may be given a few drops of pale brandy in a tea- 
spoonful of water, or may take three or four drops of sal volatile in a little 
aromatic water every few hours. If there be twitching, or any sign of 
convulsions, the child should be placed at once in a warm bath. If he 
suffer much from flatulence, a rhubarb and soda powder may be adminis- 
tered, and afterwards a teaspoonful of the following mixture every three or 
four hours : — 

fy . Tinct. rhei 3 ss. 

Spirit, chloroformi, 

Spirit, ammon. aromat aa. TT[ xxiv. 

Glycerini 3 ij. 

Aquam carui ad. § j. 

M. Ft. mistura. 

This may be given to a child of six months old. 



CONSTIPATION — TREATMENT. 623 

In children, after the age of infancy, constipation must be treated by 
attention to diet, and by the enforcement of regular habits. The diet 
should be carefully selected with regard to its digestibility, avoiding ex- 
cess of farinaceous and saccharine articles. Well-made oatmeal porridge 
is serviceable at breakfast, and broiled bacon at this meal is not only diges- 
tible but useful With his dinner the child may take a sufficiency of fresh 
vegetables and fruits, especially baked apples. All children should be 
cautioned against resisting the desire to empty the bowel, and should be 
taught regularity in this respect, as has been already recommended. 

As an occasional aperient, the compound liquorice powder (a teaspoon- 
ful mixed with a small quantity of water or milk at bedtime) is very use- 
ful, and much more to be recommended than the syrup of senna and other 
saccharine laxatives, which tend to promote acidity and flatulence. If the 
constipation is habitual, it must be treated after the manner followed in 
the case of an adult patient. The senna mixture recommended above for 
babies is useful given in suitable doses. If the child can take a pill, Sir 
Andrew Clark's prescription of small doses of podophyllin and extract of 
belladonna (one-sixth of a grain of each taken at bedtime) will usually, 
after a short time, produce a regular daily movement ; or two grains of 
the exsiccated sulphate of iron, with three grains of the aloes and myrrh 
pill, taken every night or on alternate nights, will effect the same object. 
In cases where the scanty stools consist of hard, dry lumps, a nightly dose 
of Hunyadi Janos water (one to two ounces) will quickly produce a complete 
change in the character of the evacuations, and promote a daily action of the 
bowels. In all these cases, regular exercise is of the utmost importance. 

If impaction of faeces in the bowel be complete, the treatment will vary 
according as to whether inflammation have or have not been excited in the 
intestine. If inflammation have occurred, the case must be treated as de- 
scribed in the chapter on typhlitis. If there be no inflammation, but the 
bowels are merely blocked by the accumulated scybala?, it is usually in the 
sigmoid flexure or rectum that the collection of faecal matters has taken 
place. In such cases, the persevering use of purgative enemata will event- 
ually relieve the patient. The difficulty commonly is that the solid plug 
often prevents the passage upwards of the fluid, so that this returns at once 
by the side of the tube and escapes. If the impacted mass is within reach 
of the ringer, it may usually be broken up by the use of a metallic sound. 
In a private house, a marrow-spoon, or even the handle of an ordinary 
spoon of suitable size, may be used for the purpose. In giving the injec- 
tion, the tube of the enema syringe should be wTapjDed round with hut at 
its base, and this, after introduction, should be firmly pressed against the 
anus so as to resist the escape of the fluid. A large quantity of thin warm 
gruel, with an ounce of castor-oil and half nn ounce of turpentine, must be 
injected very slowly, and the patient should be instructed to retain it as 
long as possible. In some cases, especially if the impacting mass is out 
of reach from the anus, the solid plug may resist repeated enemata. In a 
case recorded by Mr. Gray — a boy of seven years old who had suffered from 
complete stoppage of the bowels for three months — the constipation was 
eventually overcome by introducing a speculum into the rectum, so as to 
dilate the sphincter, and then directing a stream of water against the ob- 
stacle. By this means, after the stream had played for half an hour or more 
against the mass, the latter became disintegrated, and a quantity of hard 
matter like cinders was brought away, to the great relief of the patient, 

After the removal of the accumulated faeces, it is very important to keep 
the bowels regular for the future by the means which have been described. 



CHAPTER IY. 

DIARRHCEA. 

Diaeehcea in early life is a subject of the utmost importance, as to it a 
large projDortion of the deaths which occur in infancy are to be ascribed. 
The term itself is a vague one. It expresses merely an injurious increase 
in the alvine dejections, without reference to cause, and is applied equally 
to a trifling derangement, and to a serious, or even fatal illness. It there- 
fore embraces several varieties of intestinal disorder which are clinically 
distinct, although, anatomically, perhaps, they may present mere differences 
in degree of the same pathological condition. For practical purposes it 
will be convenient to describe three forms of bowel complaint. Simple 
non-inflammatory diarrhoea (mild intestinal catarrh) ; acute inflammatory 
diarrhoea (severe intestinal catarrh, or entero-colitis), and choleraic diarrhoea 
(infantile cholera). Of these, the first only will be treated of in the present 
chapter. 

In simple non-inflammatory diarrhoea, the mucous membrane of the bow- 
els is in a state of temporary irritation, resulting from a mild form of catarrh. 
The disorder is a mere derangement of function, is, as a rule, accompanied 
by no great violence of purging, and is quickly arrested by suitable treat- 
ment. By many writers, this form of diarrhoea is not separated from the 
more severe variety of muco-enteritis, which will be described afterwards. 
Its clinical characters are, however, so different, and its symptoms so much 
less serious, that it is convenient to devote a special chapter to its con- 
sideration. 

Causation. — Improper feeding is one of the most frequent causes of 
looseness of the bowels. Amongst hand-fed babies, the disorder is especi- 
ally common, and unless quickly arrested, is very apt to run on into the in- 
flammatory form, and prove serious. The food may be excessive in quantity, 
or unsuitable in quality. Often it is both, and an infant of a few months 
old is supplied with an amount of farinaceous food far in excess of his 
powers of digestion. The food is consequently carried along the alimen- 
tary canal, fermenting and irritating the mucous surface over which it 
passes, until it is discharged. A common cause of looseness of the bowels, 
is the practice, which often prevails in badly-regulated nurseries, of pre- 
paring for the infant in the morning the whole day's supply of food. The 
mixture of milk and sweetened farinaceous matter seldom remains un- 
changed for many hours together, and often, after a short time, is quite 
unfit for the child's consumption. But besides infants, children of all ages 
are subject to temporary looseness of the bowels, from the irritation of un- 
digested and fermenting food. In such cases, the alvine flow may be re- 
garded as the natural effort of the bowel to relieve itself of an unwelcome 
burden. The danger is, that in infants, and weakly children, the mild 



DIAERIKEA — CAUSATION — SYMPTOMS. 625 

catarrhal process may not cease with the expulsion of the offending sub- 
stance, but may pass on into the more serious form. 

A cause which is little less common than the above, is chilling of the sur- 
face. Children, and especially young babies, are very sensitive to changes 
of temperature, and part with their heat very rapidly. Unfortunately, it is 
at this susceptible age that the body is habitually less covered than at any 
other period of life. From the time that the child relinquishes his first 
long clothes, until his third or fourth year, he is exposed, with insufficient 
protection, to frequent changes of temperature. At all seasons, while in- 
doors, his legs and arms are bare — often his neck and shoulders as well ; 
and not seldom from the waist downwards he is covered by nothing but his 
short and scanty skirts. It is not, then, surprising that in a changeable cli- 
mate the child should be subject to frequent chills, and that diarrhoea should 
be so common a complaint. In England, the derangement is especially 
prevalent at the end of spring and the beginning of autumn— seasons when 
the warmth of the day is rapidly succeeded by the cool of the evening. 
Moreover, it must be within the experience of most medical practitioners, 
that the sudden alternations which sometimes occur, even in the height 
of summer, from excessive heat to a cool, or even chilly temperature, are 
generally followed by an outbreak of diarrhoea amongst the younger 
members of the community. Rickety children, probably on account 
of their profuse and ready perspirations, are especially liable to these 
attacks. 

Whilst cutting teeth, young children are more than usually prone to 
looseness of the bowels. In such cases, the relaxation is popularly ascribed 
directly to the process of dentition, and the child is said to " cut his teeth 
with diarrhoea." There is, however, no doubt that the teething process is 
concerned in the derangement only indirectly. During dentition, a child 
is often feverish, and pyrexia from any cause reduces the resisting power of 
the body, and renders it sensitive in an unusual degree to changes of tem- 
perature. In one case, the catarrh fastens upon the bowels, in another upon 
the stomach, in a third upon the lungs, according to the varying suscepti- 
bility of the organs ; and strictly speaking, the child suffers not because he 
is teething, but because he is feverish. 

Although looseness of the bowels from the above-mentioned causes is 
usually transient and trifling, it is liable at any time to become severe and 
even dangerous. An intestinal catarrh, unless quickly arrested, is apt to 
extend and grow violent, especially in weakly subjects ; and an attack of 
diarrhoea which begins mildly enough, may suddenly change its character 
and assume very serious proportions. 

Morbid Anatomy. — As the derangement is not in itself of much mo- 
ment, few opportunities of an examination of the intestine are afforded. 
Such, however, occasionally occur when the derangement has been present 
in a young child who is feeble and ailing from some more serious affection. 
In such cases, the mucous membrane may appear to be quite healthy, and 
if here and there a certain amount of arborescent redness is discovered, 
this is in all probability a post-mortem change. Occasionally, an excess of 
slimy mucus may be found coating the lining membrane over a greater or 
less extent of surface. 

Symptoms. — In infants, the mild intestinal catarrh which constitutes the 
non-inflammatory form of diarrhoea usually occurs suddenly. Sometimes 
it is preceded for some hours by slight griping pains, nausea^ or even vom- 
iting, a furred tongue, restlessness, peevishness, and other signs of discom- 
fort ; and occasionally, if a very indigestible substance has been swallowed, 
40 



626 DISEASE IN CHILDEEN. 

by some fever. In a short time, a profuse discharge of thin feculent matter 
takes place from the bowel, and the pyrexia, if it had been present, sub- 
sides at once. At first, the evacuations are faecal, and contain lumps of un- 
digested food. They have often an offensive sour smell, and may be frothy 
from evident fermentation. Usually, the early faecal stools are succeeded 
by thinner, smaller watery or slimy dejections, showiDg an excess of mucus, 
and tinted of a green colour. If the catarrh affect exclusively the lower part 
of the larger bowel, there is much mucus and perhaps streaks of blood from 
straining. In the first few hours the stools are usually frequent, but after- 
wards they become rarer, and five or six — seldom more — are passed in the 
course of the twenty-four hours. They are more numerous in the day than 
in the night, and are excited by liquid food, especially if this be taken warm 
and in large quantities at a time. T||ie belly is not swollen or tender, and the 
motions after the first are usually voided without paio. If frequent, they 
have a noticeable effect upon the nutrition of the child. He looks pale, and 
his flesh quickly becomes soft and flabby to the touch, although to the eye 
the body may not appear to be wasted. A thermometer placed in the rec- 
tum shows no increase of temperature. The duration of the derangement 
varies from twenty-four hours to two or even three days. If it exceed this 
period, it often passes into the more serious variety described in the next 
chapter. 

If the diarrhoea be due to a chill, other signs of catarrh may usually be 
detected. The child snuffles from slight coryza, or coughs from a trifling 
cold on the chest. 

After the age of infancy, the symptoms present little variety from those 
just described. The child may complain of discomfort in the belly, but 
preserves his spirits, often his appetite, and will not allow that he is ill. 
He is usually thirsty, and his tongue is furred, but his general health, and 
even his nutrition, seem to suffer little, if at all, from the looseness of his 
bowels. 

In children of five or six years of age and upwards a form of looseness 
of the bowels called "lienteric diarrhoea" is common. This derangement 
consists in an exaggeration of the normal peristaltic movement, which ap- 
pears to be at once excited by the taking of food. In these cases, the 
latter part of a meal is accompanied by an uneasy sensation in the belly 
which soon becomes a griping pain, and is quickly followed by an urgent 
desire to evacuate the bowels. Often the child has to hurry away from the 
table, and the motions are found to consist almost entirely of undigested 
food and mucus. The bowels act in this manner after each meal, and often 
also in the morning before breakfast. The abdominal pain may be com- 
plained of at other times without being followed by a stool. The tongue 
is slightly furred, or is clean, red, and irritable-looking. If this looseness 
continue for several weeks, as it often does, it causes considerable impair- 
ment of nutrition. 

Treatment. — If an infant be taken with diarrhoea, the treatment will 
vary according to the period at which the child comes under observation. 
If he is seen early, and there are signs of abdominal discomfort, especially 
if the motions contain lumps of undigested curd and starch, it is always 
best to assist the discharge of the offending matters by a teaspoonful of cas- 
tor-oil, or a small dose of rhubarb and soda (gr. iv.-vj. of each with gr. j. of 
powdered cinnamon). This the child will take readily if it be made into a 
paste with a few drops of glycerine. Afterwards an antacid can be ordered 
with a carminative. The following, slightly altered and modernised from 
an old prescription by Boerhaave, is very useful : 



DIAEEIICEA — TREATMENT. 627 

3 • Sapon. duri Hispanioli gr. xvj. 

Creta? prsep gr. xx. 

Syrupi flor. aurantii 3 ij. 

Aq. menthae sativae 3 iij - 

Aq. foeniculi ad. § j. 

M. 
Sig. A teaspoonful to be given every eight hours to a child between six 
and twelve months of age. To older children it can be given every six 
hours. 

If, after the action of the laxative, the stools still continue to contain 
lumps of undigested food, or if the belly remain hard and distended, it is 
well to repeat the aperient until the dejections assume a more healthy 
character. 

Even if the diarrhoea appears to be occasioned by a chill, it should be 
treated in the same way ; for there are in such cases acrid secretions which 
cause great irritation of the bowels until they are removed. At the same 
time, care should be taken that the abdomen is kept warm with a flannel 
binder, and that the child, if nursed, is restricted to the breast. If he be 
fed by haud, the milk should be diluted with barley-water, or with water 
in which a little gelatine has been dissolved, to insure fine division of the 
curd, and should be alkalinised by the addition of ten or fifteen drops of 
the saccharated solution of lime. 

In the large majority of cases, an attack of simple diarrhoea is quickly 
arrested by this means, especially if care be taken that the child is confined 
to the house and guarded from further chill. If, however, the looseness 
continue, a powder composed of rhubarb (gr. iij.) and aromatic chalk 
(gr. v.) should be given at night-time ; and in the day, a small quantity of 
laudanum should be prescribed with an antacid and warming aromatic : 

$ . Sp. ammon. aromat TTj, xx. 

Tinct. rhei TT[ xxiv. 

Tinct. opii guttse iv. 

Sp. chlorof ormi TT[ xxiv. 

Aquam carui ad. § j. 

M. 
Sig. One teaspoonful to be given every eight hours to a child of six 
months old. 

Oxide of zinc (gr. j.) ; bismuth and chalk (gr. iij. -v. of each) ; and the 
old-fashioned but not the less useful chalk and catechu mixture, are all of 
service, especially if the stools are acid and frothy. So long, indeed, as 
signs of fermentation are visible, chalk with an aromatic should form part of 
the mixture, whatever be the'combination adopted. If afterwards the evac- 
uations become thin and watery, an astringent is indicated. Such cases, 
however, ought strictly to come under the head of inflammatory diarrhoea, 
and full directions for their treatment will be given iu the next chapter. 

If the diarrhoea occur in the course of teething, there is often hesitation 
as to the course to be adopted. Some authorities have been of opinion 
that the purging should not in such a case be hastily arrested, lest the fever 
and local inflammation be thereby aggravated. There is, however, no founda- 
tion for such apprehensions. I have never seen ill effects follow from the 
suppression of the intestinal flow. On the contrary, if the infant be weakly 
and the bowels habitually irritable, the continuance of the relaxation may 
cause such depression of the strength as to place the child's life in immi- 



628 DISEASE IN CHILDEEN. 

nent danger. The wisest course to follow is, first to remove irritating secre- 
tions by a mild aperient, such as the rhubarb and soda powder, or castor- 
oil, and afterwards to prescribe one of the antacid mixtures given above. 
Boerhaave's aromatic soap draught is very useful in these cases. 

After the age of infancy children must be treated for the mild form of 
diarrhoea upon precisely similar principles to those laid down above. They 
should be confined to the house, and restricted in acid-making articles of 
food, such as fruit and sweets. A dose of rhubarb and magnesia, followed 
by a draught, several times in the day, containing spirits of sal volatile with 
chloric ether and a few drops of laudanum, or chlorodyne in some aromatic 
water, will soon restore the alimentary mucous membrane to a healthy 
condition. 

Lienteric diarrhoea must not be treated with astringents. The loose- 
ness is quickly arrested by small doses of arsenic and nux vomica. For a 
child of six years old one drop of Fowler's solution of arsenic may be given, 
with two drops of tincture of nux vomica, three times a day, before food. 
One or two drops of laudanum may be added if the looseness does not 
quickly yield. 



CHAPTER V. 

INFLAMMATORY DIARRHOEA. 

Inflammatory diarrhoea (severe intestinal catarrh or entero-colitis) is a much 
more serious disorder than the preceding. The purging may be severe 
from the first, or may begin as a mild looseness of the bowels, which quickly 
becomes more violent, and is accompanied by very evident impairment of 
the strength and interference with the general nutrition of the patient. In 
feeble children and infants it is often rapidly fatal, and even robust sub- 
jects may die collapsed after a few days. In some cases it passes into a 
chronic stage, and if not fatal to life, may reduce the child to a state of ex- 
treme emaciation and weakness. 

Causation. — The causes which have been enumerated as giving rise to 
the simple non-inflammatory form of diarrhoea may also induce the more 
serious variety of intestinal catarrh. The severity of the process excited by 
these agencies is probably often dependent upon constitutional tendency, 
or upon some special state of the system prevailing in the child at the time 
of the attack. 

Chilling of the surface and improper feeding are, no doubt, answerable 
for many of these cases. Besides these, the drinking of contaminated 
water, or the effluvium from decaying organic matter given out by the 
putrefying refuse of large cities is, no doubt, a frequent cause of the preva- 
lence of severe and often fatal diarrhoea during the summer months. Not 
unfrequently several of these causes are found in operation at the same 
time. If an infant born of poor parents, and living in a badly drained and 
crowded house, be fed in hot weather from an ill-cleaned and sour-smelling 
bottle, it may be considered certain that acute inflammatory diarrhoea of a 
violent character will very shortly follow. In bottle-fed infants, indeed, the 
disease is especially common, and is answerable for a large part of the 
mortality which occurs in cities during the first twelve months of life. 

Severe inflammatory diarrhoea appears to be almost confined to large 
towns ; and the mortality from this cause is greatest during the months of 
July, August, and September. According to Dr. G-. B. Longstaff, it is not 
so much heat alone, as heat combined with drought that gives its virulence 
to the disease ; for the mortality is greatest in years with hot, dry summers, 
least in years when the summers are cold and wet. This observer regards 
the complaint as a communicable zymotic affection, and attributes its ori- 
gin to a locally bred miasma from the soil or sewer-air. It seems, indeed, 
likely that in many of the more serious cases of acute inflammatory diar- 
rhoea there may be a strong septic element in the illness. Certainly we 
often find a degree of nervous prostration quite out of proportion to the 
amount of purging. Indeed, a state of exhaustion may continue after the 
diarrhoea has been arrested, and end in death, although days have passed 
without any excessive looseness of the bowels having been noticed. 

Weakness of the child, as might be expected, favours the occurrence of 



630 DISEASE IN CHILDBED. 

inflammatory diarrhoea ; but there are certain diseases which are commonly 
accompanied by catarrh of the bowel. Thus in typhoid fever diarrhoea is 
a frequent symptom ; and in measles and scarlatina purging may form a 
very serious complication. Again, causes which promote congestion of the 
portal system, such as cirrhosis of the liver, and diseases of the heart and 
lungs, which impede the passage of the blood from the right side of the 
heart to the left, and therefore interfere with the whole venous circulation, 
may also help to determine the derangement. 

Morbid Anatomy. — The catarrh of the intestine is seldom general, usu- 
ally it is very partial, and is limited to the large intestine and jejunum. 
On opening the bowel we find the lining membrane coated at the inflamed 
part with a layer of thick mucus containing detached epithelial scales. The 
mucous membrane itself is reddened, and often thickened, and its solitary 
glands and the glands of Peyer's patches are swollen so as to project above 
the surface. Sometimes the mesenteric glands are a little swollen. 

If the inflammation have passed into a chronic stage it is dark gray or 
dirty red in colour, and the enlarged follicles can be seen as small, pearly pro- 
jections. In some cases patches of false membrane are seen on the surface, 
especially in the large intestine. The mucous membrane then has the ap- 
pearance of being sprinkled over with bran. The little patches consist of 
exuded lymph containing epithelial scales. They vary in size and shape, and 
usually occupy the summits of the ridges of the mucous membrane. 

If the catarrhal process has lasted long or been very serious we often 
find ulcerations. These are usually seen in the large intestine, especially 
towards the lower part, and in the lower part of the ilium. The ulcers are 
seated at the follicles and result from suppuration and ulceration starting 
from the interior. They are at first circular but may extend their edges ir- 
regularly. Not rarely we find intussusceptions of the bowel. These usually 
occupy the small intestine, and several may be present at the same time. 
They are evidently produced immediately before death, for the invaginated 
portions can be readily drawn out and show no sign of congestion or swell- 
ing. 

In many cases of severe intestinal catarrh the liver is fatty. Another 
frequent complication, according to Kjellberg, is parenchymatous nephritis. 
This physician states that in 143 cases of fatal intestinal catarrh he found 
kidney disease in no less than 67. It is more common in infants than in 
older children, and is often partial, attacking only a portion of the cortical 
substance. 

Symptoms. — The symptoms of acute inflammatory diarrhoea vary to 
some extent according to the age of the child. As a rule, if the purging 
be profuse the drain upon the system causes symptoms of depression, which 
come on earlier and are more severe in infancy than at a later period of 
childhood. Moreover, in infanc^ the intestinal disorder is apt to be accom- 
panied by symptoms dependent upon parenchymatous nephritis ; and this 
complication is not so often seen after the period of the first dentition has 
come to an end. The derangement will, therefore, be first described as it 
affects infants, and afterwards as it is met with in older children. 

In infants inflammatory diarrhoea usually begins like the milder form, 
with symptoms of discomfort about the belly and some looseness of the 
bowels ; but the purging soon becomes more severe. If there be any gas- 
tric catarrh, the child often vomits ; and both the matter ejected from the 
stomach and that discharged from the bowels is acid and sour-smelling. 
The stools at first contain much curd and undigested food, but rapidly change 
their character and become thin and watery. They are brownish or greenish 



INFLAMMATORY DIARRHOEA— SYMPTOMS. 631 

in colour, and give out a most offensive odour. Unless the lower bowel be 
affected there is little mucus visible to the eye, and the stools are passed 
without straining or signs of pain in the belly. In number they vary from 
six or seven to fifteen or twenty, or even more, in the twenty-four hours. 
Their character is found to change from time to time, partly according to 
the frequency of their passage. Thus, if they follow rapidly upon one an- 
other they usually consist of dark-coloured watery fluid, which deposits thick 
feculent matter on standing. If separated by a longer interval, they become 
thicker and more distinctly faecal, and may contain small lumps of curd. 
Often they vary in character, and are at different times light and pasty, or 
frothy and dark, or green and very liquid. They are almost always very 
offensive. Under the microscope Dr. Lewis Smith has detected undigested 
particles of casein, fibres of meat, crystalline formations, epithelial cells — 
single or arranged in clusters — mucus, and sometimes blood. According to 
Nothnagel, of Jena, mucus, invisible to the naked eye, but perceptible under 
the microscope, indicates a catarrh of the smaller bowel. 

The general symptoms are very severe. The infant rapidly wastes, and 
becomes so weak that he cannot sit up. His eyes get hollow ; his face is 
very pale ; the nasal line encircling the corners of his mouth becomes 
deepened into a distinct wrinkle, and erythematous redness appears upon 
the buttocks and inner parts of the thighs from the irritation of the dis- 
charges ; the skin is dry, and the amount of urine is greatly diminished. 
Often the tongue is quite clean and red, although less moist than in health, 
and there is great thirst. If there is much gastric catarrh, the tongue may 
be -furred upon the dorsum, and vomiting is often a distressing symptom. 
The pulse is rapid and feeble. The temperature varies. Sometimes it re- 
mains unaltered or may even be subnormal ; in other cases it reaches to 
102° or 103°, rising and falling irregularly, but never dropping to the level 
of health. 

After a few days, the earlier in proportion to the profuseness of the 
drain, the child falls into a state of profound depression, with quick, feeble 
pulse, and rapid, shallow breathing. The eyes are hollow, the purple lids 
close incompletely, and the face, especially round the mouth, is livid. The 
fontanelle is deeply depressed. The tongue often gets dry and brown, and 
thrush may appear upon the cheeks and lips. Often, although the hands and 
feet feel cold, the internal temperature of the body is very high. A ther- 
mometer placed in the rectum will sometimes mark 107°, or even higher, 
although the child's general appearance is that of collapse. Thus, a little 
boy, aged nine months, had suffered from diarrhoea for a week, and was 
occasionally sick. When seen the motions were light coloured, watery, 
and offensive. His temperature (in the rectum) was 105.6° ; pulse, 176 ; 
respirations, 64. On the following morning the temperature was 103° ; but 
in the evening it rose to 107.8°, and the child died a few hours afterwards. 
Just before death the thermometer marked 106°. Another infant, ten months 
old, had diarrhoea for about a fortnight, the bowels acting five, six, or seven 
times in the day. At this time the temperature was normal. It then be- 
gan to rise, and for a few days varied between 101° and 102°. Then it rose 
rapidly to 107.4°, and the child died with all the signs of collapse. In 
neither of these cases was permission obtained to make examination of the 
body, but no complication could be discovered during life to account for 
the elevation of temperature. 

When the catarrh is seated in the larger bowel, especially if it affects 
principally the descending colon and rectum, the symptoms are more dys- 
enteric in character. Indeed, this form of inflammatory diarrhoea is often 



632 DISEASE IN CHILDREN. 

improperly spoken of as " dysentery." The infant usually cries before the 
passage of a stool from griping pains in the belly ; and the evacuations are 
discharged with great effort and straining. Often the bowel prolapses, and 
the motions contain streaks or drops of red blood. The stools themselves 
consist of slimy matter from admixture with mucus, and lumps of coagu- 
lated mucus cao be distinctly perceived in the faecal matter. Sometimes 
the straining continues for a considerable time after the passage of the 
motion, and the prolapsed bowel protrudes like a bright crimson ball from 
the anus. Often it can be returned only with great difficulty, and when 
replaced is shot out again directly by the straining. In this form the stools 
may be as numerous as when the small intestine is affected, the vomiting 
as distressing, and the prostrating effect upon the system of the constant 
purging quite as pronounced. Indeed, if the tenesmus is urgent and the 
protrusion of the inflamed bowel almost constant, the case is very likely to 
end fatally. 

If the derangement be complicated with parenchymatous nephritis, the 
signs of general collapse, into which the infant in fatal cases almost invaria- 
bly sinks, are diversified by others pointing to the kidney. According to 
Kjellberg's description of such cases the tongue is dry, the skin upon 
the abdomen is cool and dry, and its elasticity is completely lost, so that 
when pinched up it remains wrinkled, lying in loose folds ; the legs are 
stretched out and stiff, often cedematous ; the urine is very scanty, albu- 
minous, and deposits a sediment containing epithelial and hyaline casts and 
small round cells. The child vomits occasionally, sometimes shrieks out, 
and may be convulsed. In the very acute cases the infant is restless, with 
;a very rapid pulse and hot skin. He flexes his thighs on his belly, and al- 
though drowsy and stupid, screams at times with pain, and appears to feel 
acutely the slightest touch upon his body. 

In the more protracted cases the infant often falls into a comatose 
state, which from its resemblance to the third stage of meningitis has been 
called " spurious hydrocephalus." The child lies in a drowsy condition, 
from which, however, he can at first be roused. His eyelids are half 
closed ; the pupils are sluggish and may be unequal ; the pulse is rapid, 
and often intermittent ; the breathing is irregular and sometimes sighing ; 
the fontanelle is deeply depressed ; the features are pinched and sharp ; 
and the complexion is livid or even lead-coloured. The temperature taken 
in the rectum is subnormal. While in this state the stools — small, wa- 
tery, and often greenish — may continue, and be passed involuntarily ; or 
the purging may cease, but without being followed by any signs of im- 
provement. Unless energetic measures of stimulation are adopted, the 
child continues in the same state for twelve or twenty-four hours, or even 
several days, growing weaker and weaker, and death may be preceded by 
a slight convulsive seizure. 

Spurious hydrocephalus may be the consequence merely of sluggish 
circulation through the brain of impoverished blood. Often, however, it 
appears to be owing to the occurrence of thrombosis in the cerebral sinuses. 
Parrot has suggested that it may be sometimes due to ursemic poisoning 
from deficient renal secretion. 

When the disease occurs after the age of infancy, the child is usually 
able to resist the exhausting effects of the diarrhoea for a longer period 
than is possible at the earlier age ; but he rapidly loses flesh and strength, 
and if the purging is severe and is accompanied by vomiting, the features 
soon look pinched, the eyes get hollow, and the expression is haggard and 
distressed. Unless the lower bowel is affected, pain in the belly is usually 



INFLAMMATORY DIARRHOEA — CHRONIC FORM. 633 

insignificant ; but if the descending colon is the seat of the derangement, 
there is much tenesmus and griping pain, and the bowel may prolapse. 
The temperature in these cases is usually moderately elevated during the 
earlier period of the attack, but often falls to a lower level than that of 
health when the purging has produced much depression of strength. 

The stools are very watery and offensive, usually dark in colour, and if 
much milk is being taken, may contain lumps of curd. Sometimes, espe- 
cially in very hot weather, they may be yellow or green from excessive 
secretion of bile. The urine is comparatively scanty and high-coloured. 
According to Nothnagel, if the small intestine is the seat of catarrh, the ex- 
cretion of indican is in excess. When death takes place it is usually by 
asthenia ; but spurious hydrocephalus is uncommon after the period of in- 
fancy has passed, and, according to Kjellberg, kidney complication after 
that age is equally rare. 

At all ages the symptoms of prostration come on earlier and are more 
pronounced if the child is already reduced in strength when the attack 
begins, and therefore inflammatory diarrhoea occurring as a secondary 
complication in a child worn and wasted by previous illness is an exces- 
sively serious derangement. 

The chronic form of intestinal catarrh is a very obstinate and dangerous 
disorder, and unless treated judiciously is almost certain to end fatally. 
It may succeed directly to an acute attack, or may begin insidiously. If it 
occur as a sequel of the acute variety, the stools gradually become fewer 
and the more urgent symptoms subside. The child, however, does not re- 
gain flesh or strength, but remains feeble and pallid. His bowels act three 
or four times a day, and the evacuations consist of thin, dark, offensive 
fluid, or of equally offensive pasty matter and mucus. 

The insidious beginning of the chronic disorder is very common. If 
detected early and treated with judgment, it is readily arrested ; but if it 
continue unchecked, it becomes a confirmed derangement and is much 
more difficult of cure. Still, even in bad cases the disorder may be usually 
guided to a successful issue if proper measures are adopted. 

A child of eighteen months or two years of age is noticed to be looking 
pale, and his flesh is found to be flabby. Then he shows less than his 
usual pleasure at being on his legs, and if the power of walking have been 
only lately acquired, often refuses altogether to put his feet to the ground. 
These symptoms occasion great perplexity to the attendants, for the child's 
appetite continues good — often unusually keen — and his bowels are regu- 
larly relieved. On inquiry it will be found that the motions are more nu- 
merous than natural, often three or four in the day ; that they are large, 
offensive, and sour-smelling, and that in appearance they resemble a mass 
of soft putty. If only one or two stools occur in the da}*, they are often 
curiously copious ; and the mother will declare that the quantity of food 
consumed by the child, considerable as it may be, is quite insufficient to 
account for the enormous amount of matter passed from the bowels. 

For weeks, perhaps, these symptoms go on unchanged. The wasting 
continues, and all power of digesting what is swallowed seems to be lost. 
Occasionally for two or three days together the bowels are relaxed, the 
stools being frothy and sour-smelling, or thin and dark-coloured like dirty 
water ; but the diarrhoea soon ceases and the motions again become large, 
soft, and pasty, as they were before. The attacks of acute catarrh repeat- 
edly return, the intervals between them grow shorter, and eventually the 
looseness becomes a confirmed condition. Often, however, a considerable 
time may elapse before this stage is arrived at. The child for months may 



634 DISEASE IN CHILDKEN. 

remain pale and listless, with curious alternations of voracity in feeding 
and disgust for nourishment of every kind. He is not feverish but sweats 
copiously. There is no actual diarrhoea, perhaps even no increased fre- 
quency of stool. No pain is complained of. The mother will say that she 
cannot think what is the matter with the child, but that he is wasting away. 

When the diarrhoea becomes persistent, the stools vary in character from 
time to time. In any case, they have an intolerable stench ; and may be 
dark coloured and watery ; or thicker, but still liuid, like thin paste ; or 
may consist of green matter, like chopped spinach, diffused through a dark 
brown liquid. If they show a shreddy deposit, mixed with small black clots 
of blood, ulceration of the bowels may be confidently predicated, even al- 
though no tenderness of the abdomen can be detected. 

The wasting now proceeds rapidly. The child gets hollow-eyed, wrinkled, 
and old-looking. His belly swells from flatulent distention. His limbs 
often become ©edematous. He is excessively feeble, and lies quite motion- 
less, taking little notice of anything. His appetite may be good, even at this 
stage, but often it is capricious or altogether lost. The water is diminished 
in quantity, if the purging is severe, and may contain from time to time, a 
little uric acid sand. Eventually, the child sinks into a state of exhaustion, 
and dies from asthenia, or is carried off by an attack of inflammation of the 
lung. All the symptoms which have been described as spurious hydro- 
cephalus, may be noticed before death, and the diarrhoea may quite cease 
during the last few days of the illness. 

These insidious cases are more common during the second year of life, 
than at any other period, although they may also occur later. When the 
complaint arises as a result of an acute attack, chronic diarrhoea is often 
met with during the first year, and is especially frequent in infants who 
have been weaned early and fed afterwards on unsuitable food. 

Diagnosis. — Inflammatory diarrhoea, if accompanied by pyrexia, may be 
confounded with typhoid fever. The distinguishing points between these 
two diseases are pointed out elsewhere (see page 83). 

The severity and danger of the attack may be detected from the first, by 
noticing that the temperature in the rectum is raised. In simple diarrhoea, 
the temperature is normal after the first stool. It is a question of con- 
siderable interest to ascertain the exact seat of the catarrh. The presence 
of jaundice would, of course, indicate that the duodenum was involved ; and 
tenesmus, with or without prolapsus ani, would point to the rectum. From 
a series of careful and laborious investigations, carried out by Prof. Noth- 
nagel, who submitted to microscopical examination more than one thousand 
specimens of catarrhal stools, considerable addition has been made to our 
knowledge of the distribution of the lesion in cases of intestinal catarrh. 
According to this authority, mucus is passed in considerable quantity in 
other forms of catarrh besides that affecting the lower bowel, and can be 
detected by the microscope when not visible to the naked eye. The amount 
of mucus, and its more or less intimate admixture with the faecal matter, fur- 
nishes important evidence ; so, also, from the presence or absence of bile- 
stained mucus and epithelium, much information can be derived. The re- 
sults of Prof. Nothnagel's researches may be thus briefly summarised : 

If the catarrh affect the jejunum and ilium, no mucus can be seen by 
ordinary inspection of the stools ; but when a specimen is placed under the 
microscope between two thin plates of glass, islets of mucus are distinctly 
visible. We can then affirm positively that the catarrh is seated in the 
small intestine, and that the colon is healthy. If the mucus is tinted with 
bile pigment, it also indicates jejunal and ilial catarrh ; but, in addition, it 



INFLAMMATORY DIARRHOEA — DIAGNOSIS — PROGNOSIS. 635 

shows that there is increased peristaltic action of the colon and the lower 
part of the ilium. In these cases, the stools are always liquid, for if re- 
tained in the colon sufficiently long to acquire firmness, the bile pigment 
is always transformed, and the play of colours in Gmelin's test can no 
longer be obtained. Besides bile-stained mucus, cells of cylindrical 
epithelium, leucocyte-like corpuscles, and fat-globules, all tinted with bile, 
can be observed. In addition, on examining the urine, the indican 1 ex- 
cretion is found to be in excess. 

When the larger bowel is affected, no bile-tinted mucus globules can 
be perceived. The stools are of a pulpy consistence, and the mucus they 
contain is distinctly visible to the unassisted sight. The nearer the af- 
fected part of the bowel is to the caecum, the more intimate is the admix- 
ture of the mucus with the general faecal mass. If pure mucus is passed 
in large quantity, we may conclude that the sigmoid flexure or the bowel 
below it is the part involved ; and scybala embedded in mucus, point dis- 
tinctly to the rectum. 

Spurious hydrocephalus does not present much difficulty in diagnosis. 
The history of exhausting disease, the depressed fontanelle, the low tem- 
perature, and the signs of general prostration, sufficiently mark out this 
condition from the ordinary forms of cerebral disease. 

Prognosis. — Inflammatory diarrhoea is so fatal a complaint in weakly 
children that it is very important to estimate the chances of a favourable 
ending to the derangement. Much will depend upon the age of the child, 
the sanitary conditions under which he is living, and the state of his pre- 
vious health. The disease is most dangerous in babies who have been 
weaned early, and fed afterwards on excess of farinaceous food, or with por- 
tions of their parents' meals. Such infants are weakly and ill-nourished 
at the time of the attack, with irritable bowels from their unsuitable diet. 
A severe acute catarrh coming on under such conditions, rapidly reduces 
their remaining strength, and very commonly ends fatally. Older children, 
having greater vigour, are often able to battle through a complaint which 
would kill a younger and weaker subject. Therefore, after the age of in- 
fancy has passed, the prognosis is more favourable than at an earlier pe- 
riod ; but even in these cases, if the attack is violent and the purging 
severe, the danger is not slight, and the derangement may resist all our 
efforts to arrest its course. 

At all ages, the case is more serious if the temperature is high than if 
it be only moderately elevated. Also, great frequency in the stools ; vio- 
lent vomiting ; early collapse ; unusual drowsiness or stupor ; stertorous 
breathing ; convulsions, or other sign of cerebral complication, and any 
sudden marked increase in the pyrexia— all these are signs of very serious 
import. On the contrary, a fall in the rectal temperature is of good 
omen. If the internal heat of the body be found to have become normal, 
we may entertain hopes of improvement, although the general symptoms 
appear to have undergone no change. 

In the chronic form, the prognosis is also more serious in children 
under the age of two years. Another very important matter is the per- 
sistence of the diarrhoea. If the purging is a confirmed derangement, our 
chances of success are much fewer than if intervals occur, however short, 

J To test for indican : — Add to the urine to be examined, an equal quantity of fu- 
ming hydrochloric acid, and then with a pipette, pour down a few drops of strong solu- 
tion of chloride of lime. If no indican be present, the colour of the urine so treated 
becomes red or violet from the action of the test on some unknown constituent. If 
indican be contained in the urine, the colour of the fluid becomes dark green or blue. 



636 DISEASE IN CHILDKEN. 

in which the stools are merely soft and pasty without being relaxed. If 
ulceration of the bowels has occurred, we should look forward to the ter- 
mination of the illness with very serious apprehension (see Ulceration of 
the Bowels). 

Treatment. — In all cases of severe diarrhoea in the child, especially in 
the infant, our first care should be to place the patient at once upon a suit- 
able diet. This subject is of the first importance ; for it is indispensable 
to improvement that all food be withheld which is capable of fermenting 
and giving rise to acidity. Our object is to furnish the child with a diet 
which will supply nourishment to the system without leaving an undigested 
residue to irritate the bowels, and so aggravate the derangement we are 
endeavouring to cure. Milk, in particular, must be prohibited unless the 
patient be an infant at the breast. If he be suckled, it will sometimes be 
found that restricting the child entirely to his mother's breast is followed 
by improvement. Often, however, even this diet will not agree, and other 
means will have to be adopted. A hand-fed baby must be fed with whey 
and cream, or whey and barley-water in equal proportions, or with weak 
veal or chicken tea diluted with whey or barley-water. The food should 
be given cold, and in small quantities at a time. If the child is weakly, 
and in any case if he show signs of becoming exhausted, white wine whey 
is of great service. This must be given cold in suitable quantities at regu- 
lar intervals. Thus, a feeble infant will take a tablespoonful every hour 
with advantage at first. Afterwards, as the need for stimulation grows less 
pressing, other foods may be alternated with the white wine whey ; or this 
may be given only two or three times in the day. 

Koumiss has been used largely in these cases, and sometimes appears to 
agree. My own experience of this food, however, has not been quite satis- 
factory. In giving koumiss to a young child, the gas should be first ex- 
pelled by pouring the fluid several times from one vessel to another. The 
quantity allowed to be taken at each meal must be proportioned to the se- 
verity of the purging. If this be insignificant, the child may take the 
whole contents of his feeding-bottle. If, on the contrary, the looseness be 
frequent and exhausting, koumiss, like other fluids, must be given sparingly, 
and the quantity taken on each occasion must be very carefully restricted. 
The addition of Mellin's food to any of the first-named fluids is useful, and 
in most cases answers well. 

Older children should be fed, while the temperature is high and the 
purging severe, with plain whey, barley-water, and weak veal or chicken 
broths, given in small quantities; or if the strength is failing, with the wine 
whey, or brandy-and-egg mixture, and strong meat essence. When the 
first violence of the disease has abated, the patient may begin to take milk, 
but it should be well-diluted with barley-water to insure fine division of 
the curd, and be alkalinised by the addition of the saccharated solution 
of lime, fifteen or twenty drops to the teacupful. Whatever be the age of 
the patient, any sign of exhaustion must be combated by energetic stimu- 
lation. Brandy must be given internally, and the skin must be irritated 
by warm mustard baths. 

After regulation of the diet, the next matter is to see that the belly is 
kept warm. The whole abdomen should be covered with a thick layer of 
cotton wadding, and this must be kept in place by a broad flannel binder. 
If there is any tendency to coldness of the feet, they must be warmed by a 
hot bottle. 

Purity of the air is another point which is not to be neglected. The 
window should be opened — care being of course taken that the child is 



INFLAMMATORY DIARRH(EA — TREATMENT. 637 

not exposed to draught — and a free circulation of air through the room can 
be insured by a small lamp placed in the fire-grate. Few persons should 
be allowed in the sick room ; and all soiled linen should be removed at 
once to another part of the house. 

In all cases of severe intestinal catarrh, a careful watch should be kept 
over the temperature, and any great increase in the bodily heat should be 
at once reduced by tepid bathing. In tropical climates, the treatment of 
inflammatory diarrhoea by baths has been found very successful. A point 
of great practical importance in applying this method, is to remember the 
depressing effect of the illness, and to be careful that the application of cold 
is not carried to the point of inducing prostration. The more weakly the 
child, the more careful should we be so to regulate our measures, as to avoid 
a shock to the system which might be too severe to awaken any responsive re- 
action. The use of the bath at once reduces the temperature, and even in 
cases which eventually prove fatal, its immediate effect is often encouraging. 

A little girl, aged twelve months, with twelve teeth, was seized with se- 
vere diarrhoea. The stools were buff-coloured and watery, without lumps, 
and were passed very frequently in the day. After about a week, the de- 
jections became frothy, and had a dark green tint. There was much tenes- 
mus, and the bowel sometimes prolapsed. On an average, there were about 
fifteen stools in the twenty-four hours. The child was very weak, and had 
no appetite, but was thirsty. She never vomited. 

When first seen on the twelfth day of the purging, the tongue was red, with 
some fur on the dorsum. The skin was inelastic. The abdomen was distended, 
but unless the child strained, the parietes were flaccid, and there was no 
tenderness. The eyes were hollow, the mouth livid, and the nasal line was 
well marked. The fontanelle was depressed. The temperature was 103.4°. 

The child was ordered to be fed with veal-broth and barley-water in 
equal proportions, and to take as medicine, powders of bismuth and aro- 
matic chalk. After each motion she was bathed in cold water. After six 
of these baths, each of which had greatly reduced the temperature, the 
bodily heat remained normal, the stools were reduced to three in the 
twenty-four hours, and the child's appearance was much improved. She 
looked brighter, the eyes were less hollow, and there was less lividity 
about the lips. The stools were green and slimy, and were evacuated with 
straining. Unfortunately, after a few days of this improvement, although 
there was no increase in the diarrhoea, the child seemed to sink from ex- 
haustion, and died on the nineteenth day of the illness. 

In this and similar cases, the child was placed in cold water, and bathed 
for a minute or two with a sponge. When the child is very weak, it is ad- 
visable to make use of water warmed to the temperature of 70°, and to 
bathe him in this water for a few minutes, or until sufficient evidence of 
reduced temperature is obtained. Afterwards, he should be placed between 
blankets in his cot, with a hot bottle to his feet. A stimulant is usually 
required after the bath ; and may be given with advantage, also, when the 
child is taken out of his cot to be placed in the water. 

The above measures are all of great importance, and constitute in them- 
selves the main treatment of the disease. The use of drugs, although often 
of signal service in the conduct of the case, cannot be expected to lead to 
any good result unless the other matters have been first attended to. 

If the case is seen early, it is well to begin the medicinal treatment with 
a gentle laxative, such as castor-oil, or rhubarb and soda. Afterwards, if 
the temperature is only moderately elevated, not passing above 100° in the 
rectum, the aperient should be followed by an astringent mixture containing 



638 DISEASE IN CHILDREN. 

opium. For a child of six months old, two grains of the extract of hsema- 
toxylon may be combined with five drops of the tincture of catechu, and 
half a drop of laudanum in a chalk mixture, and given every six hours 
in the day and night. If the case resist this treatment, it usually goes on, 
and appears to be little influenced by astringents, however ingeniously they 
may be varied and combined. The cases we meet with in children's hos- 
pitals, have usually been treated with a variety of the ordinary binding rem- 
edies, but the diarrhoea continues apparently unaffected by changes in the 
physic. After seeing many of these cases, we are led to rely less upon the 
pharmacopoeia than upon attention to diet and the other means by which 
the disorder may be controlled. Of astringent remedies I prefer the ex- 
tracts of hsematoxylon (gr. ij-~v.), and rhatany (gr. ij.-v.) , or the tincture 
of catechu (TTj, v.-x.), to gallic acid, sulphuric acid, and lead. In my hands, 
dilute sulphuric acid has appeared to be almost inert unless given in a fair- 
ly concentrated form ; gallic acid is often disappointing as a cure for diar- 
rhoea, and lead I believe to be inadmissible for infants, as it has seemed to 
me to be not unfrequently a cause of convulsions. 

In cases which resist the ordinary astringents, the old prescription of 
dilute nitric acid with opium is often of special value. For a child of six 
months old, two drops of the dilute acid, with half a drop of tinct. opii, may 
be combined with a quarter of a drop of tinct. capsici, or two of tinct. 
zingiberis, and given in a teaspoonful of water sweetened with glycerine, 
three times a day. When the diarrhoea is accompanied by a high temper- 
ature, astringent3 are seldom of much service until the pyrexia has subsided. 
In these serious cases, the temperature must first be reduced by cool or 
tepid bathing ; and for medicine, the child may take a few drops of castor- 
oil (Til iij.-vj., according to his age), with one or two drops of laudanum, 
several times in the day. Another remedy, from which the best results some- 
times follow, is ipecacuanha. The value of ipecacuanha in small and re- 
peated doses in the bowel complaints of children, has long been known. 
Certainty, there are few drugs which have a more striking effect upon the 
mucous membrane of the intestine. The dose of ipecacuanha should always 
be combined with an aromatic. One-tenth or one-eighth of a grain may be 
given with a few grains of aromatic chalk powder in mucilage every three 
or four hours. Even in these small doses, the remedy may sometimes ex- 
ercise a depressing effect upon the system ; it is well, therefore, to combine 
with each dose a few drops of chloric ether or sal volatile. Another form 
in which the remedy may be administered is the time-honoured combination 
of Dover's powder with mercury and chalk. I have known obstinate cases 
of inflammatory diarrhoea, which had resisted other methods of treatment, 
to yield quickly to small and repeated doses of this compound powder. To 
a child of six months old, I order a quarter of a grain of each (Dover's pow- 
der and gray powder) every three hours. Ipecacuanha is also useful in 
somewhat larger doses, so as to produce a slight emetic action. Given in 
quantities of half a grain or a grain to a child of six months old twice in the 
day, it will often produce vomiting without much retching ; and if the 
stools have been previously pasty and sour-smelling, will cause a very rapid 
improvement in their character. When the lower bowel is affected, and 
there is great tenesmus, ipecacuanha is especially indicated. In such cases, 
it may be administered suspended in thin starch (gr. v. to 3 ij.) as an injec- 
tion twice a day. The castor-oil and opium mixture is also useful where 
the lower bowel is the seat of catarrh, and has great influence in allaying 
the pain and tenesmus. One-eighth of a grain of powdered ipecacuanha 
may be usefully combined with this mixture. If the stomach is very irri- 



INFLAMMATORY DIAEEHCEA — TREATMENT. 639 

table, and the diarrhoea is accompanied by excessive vomiting, ipecacuanha 
is of the utmost service. This drug, although an emetic in large doses, in 
feeble doses is a sedative ; and if given very frequently in small quantities, 
has a very striking influence in improving the condition of the patient. In 
fact, fully to exhibit the value of this remedy, we should select a case in 
which the vomiting is frequent and the tenesmus distressing, and give one 
or two drops of ipecacuanha wine in half a teaspoonful of water regularly 
every hour. Antimony, which has a similar action to ipecacuanha, is also 
useful in like cases. Two drops of the wine, combined with half a drop of 
opium, and two or three of tincture of ginger, form a very satisfactory rem- 
edy given every four or six hours. In all cases where the lower bowel is 
inflamed, an injection of tinct. opii in thin warm starch (TT| iij.-v. to 3 ss.) is 
most useful in relieving the tenesmus and checking the purging. It may be 
administered every night. Dr. Tyson recommends chloral to be used in the 
same way, and prescribes half a drachm of the chloral hydrate to two 
ounces of thin starch. Of this, one drachm is to be used at a time. A drug 
which is often useful when other astringents fail, is bismuth ; but to be 
efficacious, the dose of this drug must be large. For a child of six months 
old, it will be useless to give a smaller quantity than ten grains every four 
hours. I usually combine the bismuth with a few grains of the aromatic 
chalk powder, and have often met with very good results from this remedy. 

Directly a reduction in the temperature and an increase in the consist- 
ence of the stools show that the first acute violence of the disease is sub- 
siding, astringent remedies are called for, and the case must be treated as 
already described. 

If the lower bowel is acutely inflamed, and prolapses as a crimson ball 
which cannot be returned, or is replaced with great difficulty, the protrud- 
ed gut should be first fomented with warm water ; next, half an ounce of 
thin, warm starch, containing four drops of laudanum and five grains of 
powdered ipecacuanha, should be thrown up the rectum ; lastly, a thick 
poultice of boiled starch should be applied over the fundament. The 
enema may be repeated twice a day, but the fomentation and poultice 
should be renewed after each action of the bowels. If prolapsus occur 
later, as a consequence of relaxation of the sphincter and irritability of the 
mucous membrane at the lower part of the rectum, the bowel should be re- 
turned by pressure with the oiled finger, and if necessary may be retained 
in place by a pad. Astringent and tonic remedies internally, such as per- 
nitrate of iron and nux vomica (for a child of six months old : liq. ferri per- 
nitratis, TTJ, iij. ; tinct. nucis vomica?, TT[ ^ ; aquam ad., 3 j. ; to be taken three 
times a day), and enemata of infusion of rhatany after each protrusion, 
will usually quickly put an end to the prolapse. Ordinary cases of pro- 
lapsus ani in children, the consequence of repeated catarrhs of the lower 
bowel, without any great frequency or urgency in the dejections, may be 
readily cured in most cases by the application of an efficient flannel binder 
to the belly. The occurrence of fresh catarrhs being thus prevented, the 
relaxed mucous membrane soon recovers its tone. 

In cases where the symptoms known as "spurious hydrocephalus" are 
noticed, or in any case where signs of prostration are visible, the child 
should be placed for ten minutes in a warm mustard bath, and should be 
afterwards wrapped in flannel, with hot bottles to his sides and against his 
feet. The brandy-and- egg mixture can then be given every hour or half 
hour in doses of one teaspoonful, or if the patient be a young infant white 
wine whey may be used instead. In all cases of inflammatory diarrhoea, 
the quantity of food to be taken at one time must be carefully regulated 



640 DISEASE IX CHILDREN. 

according to the strength of the child. If the purging be severe, and espe- 
cially if it be accompanied by distressing vomiting, liquid food should be 
given in quantities of one spoonful every half hour. Sometimes no more 
than one teaspoonful can be borne at one time. 

In the chronic form of inflammatory diarrhoea, the treatment consists 
mainly in a careful regulation of the food. Milk in such a case is an irri- 
tant poison which must be strictly forbidden ; and starches are digested 
with difficulty, and must be very sparingly allowed. 

In the insidious beginning of the disorder, when large pasty stools are 
being passed, the child, if an infant, should be fed with weak veal-broth 
and barley-water in equal proportions ; whey with cream ; the yolk of one 
egg beaten up with broth or whey ; and Mellin's food mixed with whey or 
barley-water. The meals should be frequently varied during the day, and 
the quantity allowed must be strictly proportioned to the infant's powers 
of digestion. For medicine, he may take a powder of rhubarb (gr. ij.-iij.) 
and aromatic chalk (gr. iij.-v.) every night for three nights ; and in the day, 
a mixture composed of half a drop or a drop of laudanum with four or five 
grains of the bicarbonate of soda in some aromatic water. If the stools 
still continue pasty in character, although reduced in quantity, a couple of 
grains of pepsin may be given two or three times a day in water and gly- 
cerine, before food. In such young children, if the derangement have not 
passed beyond this early stage, it is usually readily arrested by this means. 
The infant should be warmly clothed, with a flannel bandage round his 
belly, and should be taken out frequently into the open air. 

In older children, if the derangement have persisted for a considerable 
time, digestion and nutrition are less easily restored. The same plan must 
be adopted of forbidding milk, and greatly restricting the quantity of starchy 
food. The child should take the yolk of an egg for his breakfast, with a 
slice or two of thin, well-toasted bread and fresh butter. For dinner, the 
lean of an under-done mutton-chop, with well-boiled cauliflower, and fried 
bread crumbs. For his evening meal, strong broth, meat- jelly, or meat-es- 
sence. It is best, in obstinate cases, to accustom the child to take malt bis- 
cuits, or malted rusks, instead of ordinary bread and toast, as the former 
are much more readily digested. Sometimes the pancreatic emulsion seems 
to be beneficial, but apart from the disagreeable taste of this preparation, 
which renders it exceedingly unpleasant to the patient, it often causes nausea 
and discomfort, and has to be discontinued. Pepsin (gr. iij.-v.) is, however, 
very useful, and the extract of malt often proves a valuable aid to digestion. 
Still, maltine must be given with caution, as, if it contain excess of glucose, 
it may encourage looseness of the bowels. 

I have found raw meat of immense service in cases where the stools 
continue pasty and offensive in spite of the most careful regulation of the 
diet. It is prepared by mincing a piece of raw rump-steak or mutton-chop, 
pounding it finely in a mortar, and then straining through a fine sieve. 
Meat so prepared may be eaten as it is, or diffused through meat-broth or 
meat-jelly, or spread upon bread and butter. It may be taken in large quan- 
tities. If possible, the child should be induced to swallow from a quarter 
to half a pound in the course of the day. Before each meal of raw meat, a 
dose of pepsin should be administered. Children soon take a liking for 
this food. At first it is only partially digested, and the decomposing resi- 
due gives a most offensive smell to the stools ; but after a few days, es- 
pecially if pepsin be taken, the meat ceases to be visible in the motions. 
By the above measures, strictly carried out, the most obstinate cases can be 
arrested. The child rapidly regains flesh and strength, and after a time 



INFLAMMATORY DIARRHOEA — TREATMENT. 641 



D' 



his power of digesting milk and starch returns. Very careful watching, 
however, is required in order to carry the illness to a successful issue. The 
stools must be inspected every day, and any sign of looseness, offensiveness, 
or hyper-secretion of mucus will require to be promptly attended to. Of- 
fensiveness of the motions is due to the presence in them of undigested and 
decomposing food. This is often the consequence of abnormal briskness of 
peristaltic action, which forces the contents of the bowel too rapidly along ; 
or it may be due to mere weakness of digestive power. In the first case, one 
drop of laudanum should be given three times a day to quiet exaggerated 
peristaltic action. In the second, the diet must be revised, especially in the 
matter of farinaceous food, and no starch unguarded by malt should be al- 
lowed to be taken. Excess of mucus may usually be quickly moderated 
by the castor-oil and opium mixture previously recommended, or by a few 
drops (v.-x.) of liq. hydrargyri perchloridi, given every two or three hours 
during the day. Slight looseness of the bowels is readily arrested by 
nightly doses of powdered rhubarb (gr. iij.— v.) and aromatic chalk-powder 
(gr. v.-viij.) ; or the latter may be given with a drop of laudanum, and ten or 
fifteen of tinct. catechu, three or four times in the day. The flannel binder 
in all these cases is as important for older children as it is for infants, and 
should be fitted closely to the abdomen, as already directed. 

If, when the child is first seen, the derangement has become a confirmed 
diarrhoea, the above plan of treatment, as regards diet, must still be the 
same. The belly should be covered with cotton wadding under a flannel 
binder, and the child should be strictly confined to two rooms. The purg- 
ing must be controlled by hsematoxylon, rhatany, and opium, given several 
times in the day in the doses recommended on a previous page ; and if 
the motions are sour-smelling, a few grains of aromatic chalk may be added. 
If the purging is obstinate, especially if ulceration of the bowels is sus- 
pected, nitrate of silver is a most valuable remedy. It is suitable to both 
infants and older children, and should be given with dilute nitric acid and 
tinct. opii in glycerine. For a child of six months old, one-eighth of a grain 
may be administered every four hours. For an older child, the quantity 
of the nitrate may be increased to one-fifth or one-fourth of a grain. The 
treatment of severe cases when ulceration of the bowel is present, is fully 
considered in another place (see page 666). 

The raw meat diet is very useful in obstinate cases, and, if the diarrhoea 
be copious, should form the staple of the child's nourishment. Stimulants 
will usually be required, and should consist of the brandy-and-egg mixture 
given as often and in such quantities as may seem necessary. 

When the purging has been arrested, the case must be treated as de- 
scribed for the early insidious form of the complaint. Afterwards, quinine 
and iron may be given, and the child should be sent, if possible, into a bra- 
cing air. A valuable tonic in these cases is the following, suitable for a 
child of three year's old : — 

3 • Pepsini porci gr. iij. 

Liq. strychnine "^1 i 

Quinine gr. SB. 

Acidi nitro-inuriatici dil TU iij. 

Aquam ad. 3 ij- 

M. ft. haustus. 

To be taken before each of the three principal meals. 

Cod-liver oil is also a useful remedy, and should never be neglected in 
obstinate cases. 
41 



CHAPTER VI. 

CHOLERAIC DIARRHCEA (INFANTILE CHOLERA). 

Choleraic diarrhoea is the most dangerous form of intestinal flux to which 
children are liable. It occurs only during the summer months, runs a 
very rapid course, induces in a few hours a startling change in the appear- 
ance of the patient, and often ends fatally. The affection has derived its 
name of choleraic diarrhoea from its resemblance in many of its symptoms 
to Asiatic cholera ; but it is not, like the latter disease, an epidemic malady, 
and appears to be essentially distinct in its nature, although in many re- 
spects so apparently similar. 

Causation. — Choleraic diarrhoea is especially a complaint of warm 
weather, and summer heat must be looked upon as a powerful predispos- 
ing cause of the disease. Other agencies, however, must come in as excit- 
ing causes, for the affection is not common in country places, and indeed 
is rarely seen out of cities. Injudicious feeding, bad drainage, and the 
effluvium arising from decaying organic matter are probably auxiliary 
causes which have a notable influence in exciting this as well as the other 
forms of gastro-intestinal disorder. Infantile cholera, as its name implies, 
is a disease of early childhood, and is more common during the first six 
months than at a later period of infancy. It is said not often to be met 
with after the first dentition is completed ; but older children are subject, 
like adults, to attacks of cholerine or summer cholera, which have all the 
characteristics of choleraic diarrhoea in the infant. Boys are said to be 
more subject to it than girls ; and robust children are attacked by the com- 
plaint as often as the ailing and the feeble. 

Morbid Anatomy. — An examination of the intestinal canal in fatal cases 
of infantile cholera reveals little to account for the alarming character of 
the symptoms by which the progress of the disease had been accompanied. 
A patchy redness of the mucous surface may be visible, but often this is 
very slight and incomplete. Indeed, it may be absent altogether, and in- 
stead of red, the mucous membrane may be paler and more bloodless than 
natural. The glands of Peyer's patches, and the solitary glands of the large 
intestine, often stand out from the surface like little translucent projec- 
tions, and sometimes the mucous membrane is softened. The softening- 
appears to be a secondary lesion, and to occur as a consequence of the pro- 
fuse serous transudation, which is one of the main features of the illness. 
The same softened state of the mucous membrane is often seen in the 
stomach. If the course of the disease is very rapid, extensive destruction 
of the epithelial coating has been noticed in the gastro-intestinal canal. 
The organs generally are anaemic. The brain is especially bloodless, and 
is said to give evidence of fatty degeneration and oedema. The kidneys 
are congested, and, according to Kjellberg, may be sometimes the seat of 
acute parenchymatous nephritis. 

Symptoms. — The outbreak of the disease may be sudden or gradual. 



CHOLEEAIC DIAKRHCEA — SYMPTOMS. 643 

Sometimes it bursts out as a violent attack of vomiting and purging, which 
quickly assumes alarming proportions, and the child speedily passes into a 
state of collapse. In other cases it begins as an ordinary purging, but 
after a few days vomiting occurs, and the stools assume the peculiar watery 
appearance which is so characteristic of this fatal malady. 

However it may have begun, the disease when established has very pe- 
culiar features. There is obstinate vomiting and very persistent diarrhoea. 
The child first throws up the contents of his stomach, and all fluid or 
medicine swallowed instantly returns. Next, the ejected matters consist 
of mucus, thin watery fluid tinged yellow, or even pure bile. The stools, 
which are at first feculent, thin, and offensive, soon lose almost all trace of 
faecal matter, and consist of a copious flow of serous fluid, which soaks into 
the diaper, and when evaporated, leaves nothing but a faint yellowish stain 
upon the linen. The quantity of fluid discharged from the bowels is some- 
times extraordinary. When thus serous, the stools are not especially offen- 
sive ; they have not the horribly foetid odour which is noticed in many cases 
of inflammatory diarrhoea — an odour which seems to cling to the diaper, 
and can be with difficulty washed away. The number of the stools varies. 
Sometimes twelve or fifteen are passed in the twenty-four hours. In other 
cases the bowels act less frequently ; but usually, if the stools are separated 
by a longer interval, a larger quantity of fluid is discharged on each occa- 
sion, so that the abstraction of water from the body is very much the 
same. 

As a consequence of the profuse drain both from the stomach and bowels, 
the patient's body wastes and dwindles with a rapidity which is surprising. 
After only a few hours, the eyes grow hollow and the nose sharp, the 
cheeks fan in, and all the features look pinched and drawn. If previously 
well nourished, the child's flesh loses all elasticity, and feels soft and 
doughy to the touch. The abdominal parietes are flaccid and sometimes 
shrunken. The skin is inelastic. Owing to the loss of water, the thirst is 
extreme. The child, if he can speak, asks constantly for drink. If an in- 
fant, he fixes his eyes upon any cup or vessel containing fluid, sucks his 
lips, and whines in a manner which is sufficiently expressive. In most 
cases, however, anything which may be swallowed is immediately returned. 

The urine is excessively scanty, and if the diarrhoea is profuse, may seem 
to be almost suppressed. The tongue may be clean, or covered with a thin 
fur. Towards the end of the disease it is often dry and brown. The pulse 
is rapid and very feeble. It often reaches 150, but is regular in rhythm. 
The temperature is generally high. The heat of the surface may be nat- 
ural, or even sub-normal, and often the extremities feel cold to the hand ; 
but a thermometer placed in the rectum registers a high level, the mercury 
rising to 104°, 105°, or even a point still more elevated. The child is ex- 
cessively restless. As long as he has strength to do so, he moves his arms 
and legs uneasily, and whimpers or cries feebly. Often he draws up the 
corners of his mouth as if to cry, but no sound is heard. He sleeps little, 
but lies in a drowsy state with eyelids only partially closed. The fontanelle 
is deeply hollowed, and in extreme cases, owing to the shrinking of the 
brain from abstraction of water, the bones of the skull can be felt to over- 
lap. 

In a very short time, unless some amendment occur, the child passes 
into a state of collapse. He lies perfectly quiet, as if dosing. His eyes 
are only half closed ; his features are sharp, and his face livid and old- 
looking. The vomiting usually ceases at this stage, but the diarrhoea gen- 
erally continues, although with diminished violence. The coma becomes 



644 DISEASE IN CIIILDEEN. 

more and more complete ; the conjunctivae cease to show any sign of sen- 
sitiveness, and the child dies quietly, or in a faint convulsion. 

In the comparatively rare cases which terminate favourably, the first 
sign of improvement usually noticed is a fall in the temperature ; the next 
a cessation of the vomiting, so that fluids can be retained upon the stomach. 
Then the stools begin to present a better appearance. The serous discharge 
becomes again tinged with fsecal matter, and the craving for drink is less 
noticeable. The diarrhoea may then cease, or thin feculent stools may con- 
tinue to be passed in small quantity for some days. In other cases the im- 
provement in the stools is the earliest sign of amendment, and the vomiting 
continues for a time, even after the purging has ceased. 

The duration of the illness is terribly brief. Often it may be measured 
by hours. Always at the end of the fourth or fifth day, the patient is either 
dead, or is evidently advancing towards convalescence. Death may take 
place in five or six hours from the first onset. In other cases the child 
survives for a longer period. Usually he dies in the course of the third 
day. 

Diagnosis — There is no difficulty about the detection of the disorder. 
The uncontrollable vomiting and diarrhoea, the intense thirst, the rapid 
shrinking of the tissues, the copious serous stools, the scanty secretion of 
urine, and the early collapse — all these form a group of symptoms whi< h is 
very characteristic, and, indeed, can hardly be mistaken. 

Prognosis. — When the disease is established, the prospect of recovery 
is faint. Early cessation of the vomiting is a favourable sign, and any re- 
turn of feculent matter in the stools allows room for hope, however unfa- 
vourable the general condition of the child may appear. Also, a fall in the 
internal temperature, although the symptoms may not have visibly im- 
proved, is a sign of amendment which is not to be disregarded. If the 
child sink into a state of collapse, he almost invariably dies. At any rate, 
I have never known an infant to recover from such a condition. Indeed, 
in any case, during the first few months of life, the ratio of recoveries is 
excessively small. 

Treatment. — On account of the persistent vomiting, which is one of the 
marked symptoms of the complaint, attempts to supply nourishment and 
support the strength of the child against the exhausting and continuous 
drain from which he is suffering, often meet with little success. Indeed, 
as long as the vomiting is frequent and distressing, and the purging severe, 
it is better to abandon all attempts to introduce food into the stomach. 
We should content ourselves with allowing the child to drink as much 
iced water as he shows an inclination to swallow ; for stinting of liquid in 
these cases has been shown to be not only cruel, but injudicious. As 
soon as any diminution in the vomiting allows us to hope that food may 
be retained, we may begin by giving a teaspoonful of white wine whey 
(iced), and repeating this quantity every twenty minutes or half hour. If 
this be vomited, a less quantity should be given ; but if this, too, be re- 
jected, it is better to postpone, for the time, any further attempts to sup- 
ply nourishment and return to the iced water. If the stomach can retain 
the whey, the child may be allowed to take it in considerable quantities, 
sucking it through the bottle like any ordinary food. If after a few hours 
there is no sign of sickness, a dessertspoonful of cream may be shaken up 
in the bottleful of whey. Milk in any shape, even breast-milk, must be 
strictly forbidden in these cases. 

Koumiss has been strongly recommended as a food in this disease. 
Dr. Archibald M. Campbell, of New York, speaks highly of its value in 



CHOLERAIC DIAERH<EA— TREATMENT. 645 

arresting the vomiting, subduing the thirst, reducing the number of the 
stools, and improving their appearance. He recommends that it should 
be given at first in quantities of half or a whole teaspoonful every ten 
minutes or quarter of an hour, and that the quantity should be gradually 
increased. While it is being taken, iced filtered water can still be used 
to quench thirst. If the white wine whey be employed, no other stimulant 
is required ; but if koumiss be used, the child will require an occasional 
dose of pure brandy, of which five or ten drops may be given at one 
time. 

On account of the early occurrence of collapse, the case should be 
watched with the utmost attention, and any sign of exhaustion requires to 
be combated by energetic stimulation. The child must be placed for five 
or ten minutes in a warm mustard bath ; and afterwards brandy (ten to 
thirty drops) must be administered, and repeated at short intervals, until 
the warmth of the extremities is restored. It must be remembered that a 
high internal temperature is compatible with considerable coldness of the 
surface ; and that it is of extreme importance to encourage the heart's ac- 
tion and improve the general circulation. Often the dose of brandy will 
have to be repeated every few minutes for a time. It is astonishing how 
large a quantity of spirit must be given in many cases to produce a suffi- 
cient effect even upon a young baby. 

If the child is seen early, before exhaustion has come on, and the tem- 
perature is found to be high, it is well to reduce the pyrexia by placing 
the child in water of 75° or 80° Fahr. If, however, there is great feeble- 
ness, the mustard-bath must be used as already described. 

Medicines given by the mouth are very disappointing in this disease. 
French authors speak highly of the value of nitrate of silver. If this salt 
be employed, it may be given in quantities of gr. ^ to gr. -J several times 
in the day. A common prescription is a combination of bismuth with 
aromatic chalk powder. If used, the dose of bismuth should be 'a large 
one (gr. v.-x. for a child of three months old), but the medicine is usually 
vomited ; and if retained, has never seemed to me to have the slightest 
effect in allaying the irritability of the stomach or arresting the purging. 
The use of the salicylate of lime has been proposed by Mr. Walter Kilner, 
and the value of the remedy has been very warmly praised by Dr. Hutch- 
ings, of Brooklyn, New York, in the treatment of these cases. This physi- 
cian administered the drug in doses of from three to five grains every two 
or three hours. If a small dose was given without effect, a larger one was 
substituted ; and the influence of the salt in controlling the purging, 
checking the vomiting, and reducing the temperature was very decided. 
The medicine was found, in most cases, to arrest the stools without modify- 
ing their character ; although, in exceptional cases, a simple diarrhoea con- 
tinued for a short time during convalescence. Another drug to which 
great value has been attached, is the bromide of potassium. It is said in 
some cases to produce a rapid improvement in the number and frequency 
of the stools. 

Enemata are sometimes very serviceable. For a child twelve months 
old, three or four drops of laudanum in a tablespoonful of thin starch, 
with a quarter of a grain of sulphate of copper, may be thrown up the 
bowel. The injection can be repeated three times in the twenty-four 
hours, and will be sometimes followed by signs of evident amendment. 

In my experience, by far the most valuable remedy is morphia admin- 
istered hypodermically. The sulphate of morphia, as being less likely to be 
converted into apo-morphia in the blood, is recommended by Dr. W. Hard- 



646 DISEASE IN CHILDREN. 

man for this purpose. The quantity employed need not be large ; in fact, 
a small dose appears to be nearly as effective as a large one. For a child 
of a year old, one-thirtieth of a grain may be used, combined with five or 
six drops of ether ; and the injection may be repeated in an hour's time if 
the symptoms continue. This treatment is best suited to cases which are 
seen early, before symptoms of exhaustion have set in. In such cases the 
effect of the sedative so introduced is to arrest the vomiting and purging 
almost immediately, without producing any signs of narcotism. The child 
afterwards requires energetic stimulation to help him out of the state of 
weakness into which he has fallen. An infant should be fed with white 
wine whey. An older child can take the brandy-and-egg mixture in fre- 
quent doses ; and it is very important to keep the extremities warm. In 
many of these cases, after the arrest of the more pressing symptoms, very 
vigilant and intelligent nursing is required to enable the child to resist 
successfully the depressing effect of the illness. Often there appears to 
be a tendency to failure of the heart's action. After making a step or two 
towards recovery, the patient may fall back again into a state of asthenia, 
and die, without any return of the gastrointestinal symptoms, or the oc- 
currence of any inflammatory complication to explain the unfavourable 
change. This tendency must be combated by mustard-baths, stimulating 
frictions to the skin, and brandy given in frequent doses. A strong mus- 
tard-poultice, placed for a few minutes over the heart, is often of service ; 
and the subcutaneous injection of ether may prove a valuable stimulant. 
In addition to the above measures, the belly must be covered with cotton 
wadding, and the air of the room should be kept pure, and frequently re- 
newed. 

In the attacks of choleraic diarrhoea or summer cholera which occur in 
older children, the use of morphia hypodermically is equally valuable. A 
sixteenth or twelfth of a grain may be used, and improvement follows very 
quickly. 

A little girl, aged seven years, was seized at 1 a.m. with violent vomit- 
ing and purging. The bowels acted very frequently, without any strain- 
ing, and the stools consisted, after the first few evacuations, of thin serous 
fluid. The vomiting continued. The child looked pinched and blue, and 
was excessively feeble. When seen at 4 a.m., the surface was cold, and no 
pulse could be felt at the wrist. The stools had the appearance of faintly- 
tinged water. The thirst was intense. 

One-sixteenth of a grain of morphia was at once administered sub- 
cutaneously, and the child was put to bed with a hot bottle to her feet. 
The diarrhoea then ceased, and although the vomiting recurred three times 
afterwards, it was each time excited by the swallowing of milk. At 9 a.m. 
the temperature was 100.4°, and a few hours afterwards — eleven hours 
after the injection — it was noted: "Condition greatly improved; much 
stronger ; some blueness about mouth ; eyes sunken ; tongue slightly 
furred, not dry ; still excessively thirsty ; complains of no pain ; pulse 
fairly good, 138." After this note, the child only vomited once or twice, 
and the bowels only acted on two occasions, the stools each time being 
thin and offensive. The patient was soon convalescent. 

The diarrhoea which sometimes succeeds to an attack of infantile 
cholera, must be treated as directed under the head of Inflammatory 
Diarrhoea. 



CHAPTEE VII. 

DYSENTERY. 

Dysentery must not be confounded with the acute catarrh of the sigmoid 
flexure and rectum which is so common in children, and also gives rise to 
severe tenesmus and pain. The affection, when it runs its ordinary 
course, is not, strictly speaking, a diarrhoea. Faecal matter is passed 
rarely, and then only as small hard scybalous masses enveloped in mucus 
— stools which bear no resemblance to the slimy feculent motions which 
constitute a familiar symptom of inflammatory intestinal catarrh. True 
dysentery is a specific disease which often occurs in epidemics, although 
sporadic cases are occasionally met with. It is rarely seen in England, 
except in the chronic form — the result of a previous acute attack in chil- 
dren who had been resident abroad. 

Causation. — Dysentery is common in tropical climates, especially in 
places which are badly drained, and therefore damp, and where the air is 
loaded with the emanations from decaying vegetable matter. On account 
of being thus endemic in ague-breeding districts, the disease has been 
thought to have some affinity with intermittent fever ; but it has been 
shown that dysentery is not necessarily generated in malarious spots, and 
that it may occur in places where ague is unknown. Foul air, impure 
water, bad drainage generally, and rapid alternations from extreme heat 
to coolness of the atmosphere are the causes to which the disease is 
especially attributed. In a case Avhich was under my care in the East 
London Children's Hospital — a little boy of five years old, in whom, after 
death, the mucous membrane of the whole large bowel was found to be 
converted into a purplish- black slough — the illness had begun suddenly 
during very hot weather, and was attributed to foul emanations arising 
from the emptying of the dust-bins of the street in which he was living. 
It is well known that amongst the poor these receptacles are charged with 
refuse of every kind, and are often most offensive from the presence of de- 
caying organic matter. Faulty nutrition and chronic digestive derange- 
ments appear to be predisposing causes which may incline the child to be 
more readily affected by the injurious influences surrounding him. The 
disease is therefore said to be more common in hand -fed babies than in 
infants at the breast. The affection, when it occurs in epidemics, has a 
tendency to propagate itself. The emanations given out by the dejections 
of a dysenteric patient are said to possess peculiarly noxious properties, 
so that any one incautiously inhaling the effluvium is likely to take the 
disease. 

Morbid Anatomy. — la the earliest stage of dysentery the mucous mem- 
brane of the colon and rectum is congested, and is swollen from inflam- 
matory infiltration into its substance and the underlying areolar tissue. 
The colour of the membrane becomes rosy red, or may pass through 
the various shades of purple to slate gray of a very deep tint. At the 



648 DISEASE m CHILDREN. 

same time the solitary glands project from the surface, and are enlarged 
to the size of a millet seed or a small shot. The inflammation sometimes 
occurs in patches, which are separated by more or less healthy-looking 
membrane, and these run together so as to cover a considerable extent of 
surface. A false membrane may be found adhering to the inflamed area. 
This can be separated as a thin opaque film which dips down into the fol- 
licles of Lieberkuhn. It consists of an inflammatory hyperplasia of the 
follicular epithelium. 

If the disease pass beyond this stage, superficial ulcerations are seen. 
Sloughs form upon the surface, and separate, exposing ragged, irregular 
ulcers with swollen, abrupt edges. Dr. Parkes was of opinion that the 
ulcers began in the distended follicles. Dr. Maclean believes that they are 
produced by sub-mucous purulent effusion which detaches the mucous 
membrane. This becomes gangrenous and is thrown off. The sloughs 
vary in size. If the process is rapid, large sloughs may be detached, and 
sometimes casts of the intestinal tube are eliminated unbroken. Their 
tint is yellow or ash-coloured, or even almost black. The ulcers are cir- 
cular or irregular in shape, and are large or small according to the extent 
of mucous membrane destroyed. The floor of the ulcer is usually formed 
of the sub-mucous tissue, but the lesion may extend to the muscular coat, 
or may even perforate the bowel as in typhoid fever. 

The destructive process is most intense in the lower part of the colon 
and in the rectum ; but the inflammation may involve the whole colon, and 
even pass the ilio-csecal valve into the lower part of the ilium. If the 
child survive, cicatrisation may occur. A fibrinous exudation is thrown 
out on the floor of the ulcer, and becomes gradually organised. 

Lesions may be found iu other organs. The mesenteric glands may 
be swollen, the abdominal organs may be congested, and abscess of the 
liver may occur. In a little girl, aged three years and a half, who died in 
St. Bartholomew's Hospital under the care of Dr. Andrew, two abscesses 
were found in the liver. The child had never lived out of England, but 
had suffered for two months from an attack of dysentery, succeeding to 
prolonged diarrhoea of ten months' duration. One of the abscesses was 
situated in the right lobe, and was as large as an orange. The second, no 
larger than a filbert, occupied the left lobe. In the neighbourhood of the 
abscesses the structure of the liver was healthy. The whole of the large 
intestine was extensively ulcerated. 

The chronic form of dysentery is not always the consequence of un- 
healed ulcers. Still, in many cases ulceration is present. In advanced 
cases the intestinal tube may be atrophied, with complete disappearance 
of its glandular structures, and extreme thinness of its coats. In a less ad- 
vanced stage, the areolar tissue, and even all the coats of the bowel, may 
be greatly thickened. 

Symptoms. — The illness begins with slight fever, loss of appetite, and 
sometimes nausea. The child complains of uneasiness in his belly of a 
colicky character, but his sufferings do not seem to be very severe. Then 
a sudden feeling of tenesmus urges him to evacuate the bowels, and the 
contents of the rectum are discharged, more or less coated with tenacious 
mucus. The passage of the motion, however, produces little or no relief. 
The desire quickly returns, so that the child almost constantly requires 
the stool, and sits straining with extreme violence. Nothing, however, 
is voided but offensive mucus, with occasional minute scybala. The mu- 
cus may be streaked or mixed more or less intimately with blood. In 
bad cases, it resembles a rose-coloured jelly. All this time the griping 



DYSENTERY — SYMPTOMS. 649 

continues. The child often screams with pain, and may be found resting 
on his knees in his bed, with his head buried in the pillow. Still, there is 
little or no tenderness of the belly. The face is pale, with a distressed 
expression. The child cannot sleep. His tongue is white, and his skin 
dry. He seldom complains much of thirst, but eats little, either from loss 
of appetite, or from the increase of abdominal pain, which he soon finds is 
provoked by the taking of food. Sometimes, for the first few days, the 
stools may continue to be feculent. Then, as the griping pains and te- 
nesmus increase, the dejections become more scanty and frequent, and 
consist of fsecal matter mixed with gelatinous mucus. 

The disease does not always begin thus mildly. It may be ushered in 
by a severe rigor, or an attack of convulsions, with high fever, distressing 
griping pains, and almost constant tenesmus. There is burning pain at 
the anus, and the child, if permitted, will remain, as long as his strength 
allows, almost constantly seated on the night-stool. As in cases of acute 
inflammatory diarrhoea, the straining may induce prolapse of the rectum. 
The mucus passed from the bowels is bloody almost from the first ; and 
sometimes pure blood, bright or dark and clotted, may be evacuated. 
However it may have begun, if the disease last beyond a week without 
improvement, sloughy matter begins to be discharged from the bowels. 
The stools, instead of consisting merely of offensive bloody mucus, begin 
to contain dark- coloured, shreddy matter, mixed with reddish, dirty water. 
The odour of these stools is intolerably foetid, and grows more and more 
insupportable. The particles of slough generally get larger in successive 
dejections, and sometimes cylindrical portions of dead and putrefying 
mucous membrane may be discharged unbroken. It is comparatively 
seldom, however, that this stage is reached in the case of a child. The 
disease is so exhausting a one that death usually takes place before much 
sloughing of mucous membrane has had time to occur. Sloughing is 
rarely found in children under twelve years of age. 

The abdomen usually becomes distended as the disease progresses, and 
there is often some tenderness on pressure over the colon. The weakness 
now becomes very great. The child lies back with a pinched, haggard 
face, sleeps little, and is very restless. His hands and feet are apt to be 
cold, although the internal temperature is high. He is thirsty, but cares 
little for food. He may be troubled with vomiting. His water is scanty 
and high-coloured ; sometimes it is passed very frequently, but retention 
of urine is apt to occur, and require the use of a catheter. His tongue, 
very furred on the dorsum, becomes red at the tip and edges, and often dry. 

In favourable cases the distressing symptoms gradually subside. The 
temperature becomes normal ; the tenesmus grows less and less, and dis- 
appears ; the stools lose their blood and contain much grayish mucus ; 
they begin again to show signs of feculent matter; the insupportable 
dysenteric odour diminishes; the tongue cleans, and the appetite and 
spirits improve. 

In fatal cases the abdomen is distended ; the pulse is very rapid and 
feeble ; the prostration is extreme ; the face is dusky and haggard ; the ex- 
tremities are cold ; the child grows delirious, or sinks into a state of stupor, 
in which he dies. Towards the end paralysis of the sphincter may occur, 
so that the outlet of the rectum is seen wide and gaping. In exceptional 
cases oedema of the lower extremities is noticed ; and Dr. S. C. Busey 
states that this is sometimes associated with discolouration of the skin of 
the feet and legs. 

A certain variety in the symptoms can be noticed in different cases. 



650 DISEASE IN CHILDREN. 

The tenesmus is distressing in proportion to the degree to which the rec- 
tum may be implicated. If, as may happen, this part of the colon is only 
slightly involved, the straining may be insignificant, or even altogether ab- 
sent. In such a case the dejections are more feculent, and contain altered 
bile mingled with the mucus and blood. The number of the stools is very 
variable. There may be from two or three to ten or twelve, or even more, 
in the hour. In the latter case, even if the quantity of mucus discharged 
on each occasion be scanty, the whole amount passed in the day and night 
may be very considerable. The temperature is elevated. The mercury in 
the evening is often found to rise to 102° or 103°, but sinks in the morn- 
ing to below 100°. 

If the child die, death usually takes place from exhaustion, the patient 
being worn out by pain, want of sleep, and the profuse discharge of a 
highly albuminous fluid from the bowels. Sometimes, however, the fatal 
termination may be reached in a different manner. The disease may 
appear to take a favourable turn, and the dysenteric symptoms may have 
even subsided, when the child is suddenly seized with convulsions, then 
sinks into a state of coma, and dies in a few hours. Dr. S. C. Busey has 
connected these cases with thrombosis of the cranial sinuses — a complica- 
tion which is always to be feared in the infant, when his strength is pro- 
foundly impaired by exhausting disease. 

After the subsidence of the acute symptoms, dysentery often passes 
into a chronic stage. The child remains pale and thin, and continues to 
lose flesh. His bowels are open several times in the day, and the motions, 
which consist of scybala and fleshy-looking lumps, are passed with strain- 
ing. His tongue tends to be dry, and is often glazed, or is fissured with 
transverse cracks. He complains of frequent pains in the belly of a colicky 
character, and these are usually excited by taking food. The child is 
habitually thirsty, and is sometimes feverish at night. Such cases may go 
on for months, or in older children for years. Even in the most favour- 
able cases, convalescence is usually slow, the bowels being costive and 
troublesome for a considerable time after the disease is at an end. The 
colon often remains torpid, while the irritability of the rectum continues ; 
so that, although the apparent need of evacuation is urgent, and the 
straining distressing, small stools consisting of scybala embedded in 
mucus are alone discharged. 

Diagnosis. — As long as the stools continue to be feculent, the inflam- 
matory process may be judged to be as yet in an early stage. Afterwards, 
when gelatinous mucus, clear or blood-stained, is passed unmixed with 
true faeces, or containing merely hard small scybala, we may conclude 
that the inflamed area is still limited to the rectum and the lower part of 
the colon. If later, when the tenesmus and griping pains are severe, the 
mucus is again contaminated with thin feculent matter, it is probable 
that the inflammation has extended higher and has involved the upper 
part of the colon, and, perhaps, a portion of the ilium. 

In the earliest stage there appears to be nothing special in the 
symptoms themselves to indicate that the disease is anything more than 
an ordinary attack of severe intestinal catarrh. Afterwards, when the 
affection has become more fully developed, the characteristic fcetor of the 
dejections at once reveals the nature of the illness. Intussusception of 
the bowel is also marked by the passage of blood-stained, non-feculent 
mucus, combined with great straining and severe colicky pain. The distin- 
guishing points between the two diseases are elsewhere described (see 
page 674). 



D Y SENTERY — PROGNOSIS — TREATMENT. 651 

Prognosis. — The danger of the case is in proportion not only to the 
severity of the attack, but also to the time at which the patient comes 
under observation. Dysentery is a disease in which early treatment is of 
the utmost importance. If the child be seen during the first few days, or 
even before the end of the first week, he will probably recover under 
judicious treatment. Absence of severe depression of strength and spirits, 
placidity of expression, and a fair pulse are all signs of favourable import ; 
and an early return of feculence in the stools, if combined with a diminu- 
tion in the colicky pains and tenesmus, may be taken as an indication of ap- 
proaching convalescence. On the contrary, early prostration, a haggard 
facies, a feeble, frequent pulse, great restlessness, hiccough, a dry tongue, 
a gangrenous odour from the stools, and, especially, delirium — all these 
symptoms should occasion the utmost anxiety. 

If, after the cessation of the ordinary dysenteric symptoms, the child 
remain prostrate and stupid, lying in a drowsy state with eyes only par- 
tially closed, his pupils sluggish, his breathing irregular or of the Cheyne- 
Stokes type, we should fear the occurrence of cranial thrombosis. 

Treatment. — If the child is seen early, he should be put into a bath of 
the temperature of 95°, and be kept there for ten minutes, or a less time 
if he feel faint. He should be then put into bed with hot fomentations 
to his belly, and take a draught composed of castor-oil in conjunction with 
rhubarb and laudanum, in some aromatic water. This combination is 
believed to have originated with the late Dr. John Scott, examining physi- 
cian to the H. E. I. Company. It was kindly communicated to me by Dr. 
Chevers, who, in his own large Indian experience, has been accustomed to 
rely greatly upon this remedy if given sufficiently early in the disease. 
To a child of ten years of age the draught may be given in the following 
proportions : 

I£. Tinct. opii TT[ v. 

Olei ricini, 

Tinct, rhei comp aa. U[ xl. 

Aquam cassise ad. J ss. 

M. ft. haustus. 

If after this draught the bowels act more than twice in the next twelve 
hours, an enema containing ten drops of laudanum in half an ounce of 
starch- or gum-water, may be thrown up the bowel. In the case of children, 
opium should be used with especial care, on account of the early prostra- 
tion which is so apt to occur in this disease. If given at the first, its use 
should not be continued too long. Dr. Morehead speaks wamingly against 
a too prolonged use of opium, which he says makes the dejection pasty 
and scanty, and is injurious to favourable progress. 

If the practitioner fear the use of opium by the mouth, ipecacuanha is 
as useful a remedy in the young subject as it is in the adult. Six grains 
may be given to a child ten years of age ; two, three, or four grains to a 
younger child. The dose must be mixed with as little fluid as possible, 
an 1 is to be repeated every day at sufficient intervals for the child to be 
able to take nourishment ; for the ipecacuanha must not be given until 
two hours have elapsed after food. Usually, twelve hours may be per- 
mitted to pass between successive doses of the drug. The diet should 
consist of meat-broths, thickened, if necessary, with boiled sago or arrow- 
root ; and of boiled milk diluted with barley-water, and alkalinised with a 
few drops of the saccharated solution of lime. The child must be kept 



652 DISEASE IN CHILDREN. 

as quiet as possible in his bed, and painful tenesmus must be treated with 
injections of opium and starch, and by hot applications to the belly and 
anus. All through the acute stage the child should be rigidly confined to 
his bed. The air of his room should be kept pure by open windows and 
the proper use of disinfectants ; and all excreta should be disinfected be- 
fore removal from the sick-chamber. 

If the case is seen early, or is of a comparatively mild character, the 
above treatment will be usually effectual in checking its further develop- 
ment. In the very severe cases, or those which are seen after the end of 
the first week, when gangrenous sloughs are being passed, the belly should 
be covered, as in the former case, with hot applications or turpentine 
stupes. Ipecacuanha should be then given in one full dose (gr. vj.-viij. to 
a child of ten years of age), and the quantity can be repeated in eight or 
ten hours. If thought advisable, a few drops of laudanum can be given 
half an hour before the ipecacuanha. After taking the latter the child 
should be kept perfectly quiet, and must take no food or fluid. If he be 
very thirsty, however, he may be allowed to suck small lumps of ice. Dr. 
Maclean speaks very highly of the value of the remedy so administered. 
According to this physician, the straining and colic subside, the blood 
and slime disappear from the stools and are replaced by feculent matter, 
the skin becomes moist, and the patient falls into a quiet sleep. 

The value of mercury in the treatment of dysentery is a question upon 
which very opposite opinions are held. While some writers warmly advo- 
cate its use, others as warmly denounce its employment. The tendency 
of the present day, however, appears to be to neglect mercurials in favour 
of ipecacuanha. Dr. Morehead was accustomed to prescribe a combina- 
tion of calomel or blue pill, ipecacuanha, and opium, every four, six, or 
eight hours ; and to give, in addition, a small, occasional dose of castor-oil. 
This treatment he considered especially applicable to the first few days of 
the disease, although it is also suitable at a later period. He relates the 
case of a child, three years of age, who had been ill with dysenteric symp- 
toms for eighteen days. Two grains of ipecacuanha, three of extract of 
gentian, and one each of Dover's powder and blue pill, were given every 
three hours, with great benefit. When, after a few days, feculent matter 
reappeared in the stools, the opium was omitted from the prescription, 
and the other remedies were given for some days longer. 

Whether mercury be given according to this method, or the child be 
treated with ipecacuanha alone, as is the more modern practice, an occa- 
sional dose of castor-oil is often indicated. If the abdomen becomes full 
and tense, and the dejections are scanty, a dose of the oil (two teaspoonfuls 
to a child ten years of age) may be given with advantage. If the tenesmus 
is distressing, an enema of starch and opium, in the proportions already 
recommended, may be used at sufficient intervals. If, towards the end of 
the disease, the child appears much enfeebled, the brandy-and-egg mix- 
ture should be given. 

In the case of an infant, the treatment varies in some degree from that 
found useful in older children. Ipecacuanha is not to be recommended 
for patients under twelve months old ; for, according to Mr. Scriven, in- 
fants of this age do not bear well the nausea and starvation which this 
treatment involves. For these patients calomel is a preferable remedy. 
To a child eight or ten months old half a grain of calomel may be given 
morning and evening, and an enema containing one or two drops of laud- 
anum twice in twenty-four hours. Mr. Scriven speaks highly of lancing 
the gums in all cases of dysentery in teething infants. He disapproves of 



DYSENTERY — TREATMENT. 653 

farinaceous foods; and even milk — unless the child be at the breast— he 
considerably restricts in quantity, preferring to rely for nourishment 
upon beef-tea and chicken-broths. As in the case of other forms of bowel 
complaint, these meat-broths may be advantageously combined with an 
equal proportion of barley-water. 

In no instance should the ordinary astringent remedies be used while 
the illness is acute ; but when the disease passes into the chronic stage, 
they may be judiciously resorted to. In such cases, large doses of bismuth 
with aromatic chalk may be given ; rhatany and catechu are often of ser- 
vice ; and the pernitrate of iron is an especially valuable remedy. Ene- 
mata of weak nitrate of silver (half a grain to the ounce) are often of con- 
siderable value, the bowels having been previously cleared out by a copious 
injection of warm water. These injections should be large, and must be 
given very slowly. For a child ten years old a couple of pints may be 
used. Instead of a nitrate of silver injection, simple warm water may 
be employed, or a solution of alum (gr. xv. to the ounce) as recommended 
by Mr. Scriven. While these remedies are being made use of the child 
should take a daily dose of Dover's powder, if the straining and abdom- 
inal pain continue. 

Cases which have resisted treatment by astringents will sometimes 
yield readily to ipecacuanha in doses of one grain three times a day, with 
an occasional injection of laudanum and ipecacuanha in warm starch if 
the tenesmus is distressing. At the same time the food should consist 
of strong meat-essence, well-boiled rice, pounded under-done meat, and 
boiled milk, if it agree. Eggs are often not well borne in these cases. 

A remedy which is very useful in the chronic stage of dysentery is the 
per chloride of mercury given in quantities of ten or fifteen drops several 
times in the day. It may be usefully combined, as Dr. Ellis has sug- 
gested, with the tincture of cinchona. Sometimes the perchloride has 
been found to be more useful in very small doses frequently repeated, as 
five drops every two or three hours. In any case, if the dose is small it 
must be repeated more frequently in the day. 

In all cases of chronic dysentery, great care should be taken that the 
belly is duly protected from alternations of temperature by a broad flannel 
bandage, that every attention is paid to promoting the action of the skin, 
and that the surface of the body is kept perfectly clean. A complete 
change of climate to a bracing sea-air is of the utmost service in complet- 
ing the cure. 

During convalescence from dysentery the child's appetite is often 
enormous. Great watchfulness must be therefore used that he do not eat 
a quantity of indigestible substances, such as new potatoes, unripe fruit, 
or great excess of farinaceous matters and sweets. He should live prin- 
cipally upon meat once cooked, eggs, fresh-made broths and milk, and 
wine, in the shape of port or sound claret, may be allowed him with his 
dinner. 



CHAPTER Till. 

GASTROINTESTINAL HEMORRHAGE. 

H^moeehage may occur in the young subject both from the stomach and 
bowels. In gastric haemorrhage the blood may be vomited directly from 
the stomach, or may pass down the alimentary tube and be voided dark, 
and more or less altered in appearance, with the stools. The presence of 
blood in the evacuations is, therefore, no proof that the source of bleeding 
is in the bowels. Nor, indeed, does blood ejected from the mouth always 
come from the stomach. Even blood which is brought up by evident 
retching, and intimately mixed with curdled milk, may not, and often does 
not, owe its origin to the gastric mucous membrane. Infants at the 
breast not unfrequently vomit blood which is drawn with the milk from 
the breast of the mother. Cracked nipples are often very irritable, and 
bleed easily. In such cases, the act of sucking may determine a haemor- 
rhage from the fissure, and a large quantity of blood may be swallowed by 
the child. At the end of the meal this is often vomited with part of the 
milk which has been taken, and is a cause of great alarm to the parents. 

In older children who suffer from epistaxis, the blood which flows down 
into the throat from the posterior nares is almost invariably swallowed. 
If this be large in quantity it is sometimes vomited, and appears then to 
have been thrown out by the stomach. So, also, ulceration of the back of 
the throat and of the gums, such as is seen occasionally in scrofulous 
and badly-nourished children, may be a cause of bleeding. If at the same 
time the child be suffering from disordered stomach, and vomiting be 
frequent, the efforts of retching may determine a flow of blood from the 
ulcerated surface. The blood mixes with the contents of the stomach as 
these pass through the mouth, and gives the appearance of haemorrhage 
from the deranged gastric membrane. I have known such a case to occur 
and be a cause of great perplexity. 

Causation. — Real gastro-intestinal haemorrhage may be due to many 
different conditions. There is a special form of haemorrhage which is 
occasionally seen in new-born infants as a consequence of causes which 
have not even yet been fully made out. Melcena neonatorum occurs 
usually within a few hours of birth. It is said to be more common in 
girls than in boys, although this is not the experience of all observers, and 
sturdy, well-nourished children are as amenable to it as the feeble and the 
frail. The occurrence is fortunately very rare. Sometimes it has been 
known to follow a tedious labour, in which the child's head had suffered 
great compression. In other cases the respiratory function after birth 
had been established with difficulty. Often, however, the bleeding can be 
attributed to no such reason. Sometimes it appears to be the direct 
result of ulceration of the stomach and duodenum. Such a lesion has 
been occasionally discovered in the new-born babe, and has been ascribed 
to follicular gastritis by Billard; to an embolism of the umbilical vein 



GASTRO INTESTINAL HEMORRHAGE — CAUSATION. 655 

near the liver, and extending for some distance into its branches, by 
Landau ; and by Steiner, to a fatty degeneration of the blood-vessels. 
An example of such a gastric ulcer was shown by Dr. Goodhart in 1881, 
at the London Pathological Society. A new-born infant had died from 
haematemesis thirty hours after its birth. The child's appearance was 
healthy. On examination of the body, after turning out the blood-clot 
with which the stomach was distended, a small, oval ulcer, one-eighth of 
an inch in length, was seen at the cardiac end of the stomach and close to 
the greater curvature. This sore was clean-cut, sharp-edged, and firm in 
texture. In its floor was a dark speck, which proved, on close inspection, 
to be an open vessel. It is, however, uncommon to find any distinct 
breach of surface. In the large majority of cases the haemorrhage appears 
to be capillary, and nothing but a congested state of the vessels of the 
stomach is discovered on examination of the body. 

Some writers, especially Grandidier and Eitter, have attributed the 
bleeding to a condition allied to haemophilia ; and certainly in cases where 
death results from profuse capillary haemorrhage in the new-born child, 
some special and unusual tendency to bleed from slight causes must evi- 
dently prevail. In one of four cases published by Dr. Halliday Croom, a 
marked hemorrhagic tendency existed in the father. In another, although 
no family predisposition could be detected, the child himself had an evi- 
dent tendency to bleed, for the pressure of the forceps with which the 
infant was delivered had produced an extensive ecchymosis on either side 
of the head. In a child possessing this unfortunate tendency, any cause 
which interferes with the establishment of respiration will increase the 
pressure on the veins, and may thus determine an effusion of blood from 
the capillary system. Still, with regard to this supposed constitutional in- 
firmity, it must be remarked that melaena neonatorum is said not to have 
been especially observed in families subject to true haemophilia ; and that 
of infants who survive, few show in after life any particular tendency to 
haemorrhage. 

In older children gastro-intestinal haemorrhage may be due to either 
general or local causes. 

Of the general causes, hemorrhagic purpura is perhaps the most com- 
mon. In this disease the bleeding occurs not only from the stomach and 
bowels, but also from the nose, mouth, and kidneys, and into the subcu- 
taneous tissue. The tendency to haemorrhage is only a temporary phe- 
nomenon, and ceases when by treatment or otherwise the condition of the 
patient has become improved. 

In haemophilia the tendency is permanent, and persists to the end of 
life. As in the former case, the bleeding is not confined to the gastric or 
intestinal mucous membrane, but may occur from any mucous surface and 
into the subcutaneous tissue. 

In the malignant forms of all the eruptive fevers general haemorrhage 
may also occur. In such cases the symptom indicates a profound con- 
tamination of the system, and is of most unfavourable augury. 

The usual form of gastro-intestinal haemorrhage met with in the child 
arises from purely local causes. Ulceration of the bowels, such as occurs 
in typhoid fever, in cases of long-standing intestinal catarrh, and as a con- 
sequence of tubercular or scrofulous disease, is a common source of bleed- 
ing. The same symptom is seen in the ulceration arising from dysentery. 
In intussusception a prominent feature is the passage of blood and blood- 
stained mucus from the bowel. The irritation of worms will sometimes 
induce bleeding from the mucous membrane ; and intestinal derangements 



656 DISEASE IN CHILDREN. 

which give rise to straining, especially if the bowel prolapse, are a common 
cause of admixture of blood with the stools. 

There is one other cause of hemorrhage which must be mentioned. 
This is polypus of the rectum. Polypi are said not to be uncommon under 
the age of ten years, and to occur more frequently in boys than in girls. 
These fibro-cellular growths spring from the sub-mucous tissue, and are 
covered by the mucous membrane. They are more vascular in the child 
than in the adult, with a greater tendency to bleed, and are attached by a 
slender pedicle which readily gives way. The polypus varies in size from 
a pea to a marble, and may be sometimes seen within the bowel, if near 
the sphincter, looking like a bright red cherry. It bleeds easily, both dur- 
ing the passage of a stool and also independently of defecation, and if its 
seat is near the outlet, the effused blood may be mixed with mucus. 

Symptoms. — In the case of the new-born baby, the hemorrhage which 
is special to this period of life begins usually within a few days of birth — 
in the majority of instances within the first twenty-four hours. It may, 
however, be delayed. Of fifty cases collected by JDr. Croom, the bleeding 
took place : — in thirty, between the first and sixth day ; in eight, between 
the sixth and eighth ; in four, between the eighth and twelfth ; and in 
eight, between the twelfth and eighteenth day. The blood is sometimes 
ejected from the stomach as well as passed from the bowels. Sometimes, 
however, melena occurs without hematemesis ; and less commonly, hema- 
temesis without melena. Of eight cases seen by Lederer, four had 
hemorrhage from both stomach and bowels ; three from the bowels alone ; 
and one exclusively from the stomach. 

The appearance of the blood may be preceded -by great restlessness and 
pallor, a sunken belly, and sudden prostration. When the blood appears 
externally the infant seems to suffer no pain. He passes apparently an 
ordinary stool ; but this, on inspection, is found to consist either of dark 
treacly matter from admixture with meconium, or of dark pure blood. If, 
at first, dark and contaminated with the contents of the bowels, the blood 
soon becomes red and unaltered. In quantity it is often sufficient to soak 
the linen and the diapers. The dejections succeed one another rapidly, 
and after each passage the child is left cold and motionless, and seem- 
ingly exhausted. In rare cases, if the discharge is sudden and copious, 
he may be convulsed. After a time he revives somewhat, and cries feebly ; 
but if the flow be profuse, soon falls into a collapsed state. He lies quietly, 
with pallid face, cold extremities, an almost imperceptible pulse, and a 
sunken fontanelle. 

After continuing for about twenty-four hours, the hemorrhage, if the 
child survives, usually stops. In most cases blood ceases to be ejected 
from the mouth before the flow from the bowels is at an end. Sometimes, 
after a temporary intermission, the bleeding returns, and may continue, in 
diminished quantity, for several days longer. When the bleeding begins 
for the first time after the fall of the cord, hemorrhage may also occur 
from the umbilicus. Pale watery blood oozes from the navel, and the flow 
persists in spite of all efforts to arrest it. In some cases the effusion of 
blood is confined to this region, but more commonly it is quickly followed 
by hemorrhage from the bowels, and, in some cases, from the ears, the 
gums, the vagina, and into the skin. 

If the hemorrhage be profuse the child may not recover from the 
state of collapse into which he has fallen. In the favourable cases he 
gradually improves, but remains weakly and pallid for some time after- 
wards, with a tendency to intestinal catarrh. 



GASTROINTESTINAL HEMORRHAGE— DIAGNOSIS. 657 

In later infancy and childhood, gastro-intestinal hemorrhage, arising 
from the causes which have been mentioned, usually occurs in the form of 
nielaena. The bleeding is, as a rule, more profuse when it is excited by 
causes acting through the system generally than when it occurs in conse- 
quence of a purely local lesion. In hemorrhagic purpura large quantities 
of blood may be passed per anum, bright red and clotted, or more or less 
altered and blackened. In this disease, as also in haemophilia and in the 
malignant forms of the specific fevers, the tendency to haemorrhage is a 
general one. The nose and gums bleed easily, the skin is spotted with 
petechia?, or larger hemorrhagic stains, and the urine is often discoloured. 

When the bleeding occurs from local causes the effusion is scanty, as 
a rule, and is evacuated from the bowel, pure, or mixed with the ordinary 
faecal dejections. In typhoid fever haemorrhage is the exception in young 
subjects. In this and the other forms of intestinal ulceration the bleed- 
ing, when present, is seen in the form of small black clots at the bottom 
of the chamber-pan. In dysentery, and in cases of invagination of the 
bowel, the blood is brighter, and is passed pure, or mixed with mucus. It 
may amount, in the latter disease, to several ounces, but is rarely seen in 
so large a quantity. Usually only a few teaspoonfuls are passed at a time, 
and the discharge is only effected with excessive straining and pain. The 
irritation of worms is not often accompanied by bleeding, but in rare 
cases a bright red clot may be passed per anum. Catarrh of the lower 
part of the colon, especially if the bowel prolapse, may give rise to slight 
haeruorrhaq'e. The blood is usuallv in the form of li^ht-coloured streaks, 
but sometimes small red lumps may be evacuated. 

In polypus of the rectum the blood is also bright red, and may be in 
considerable quantity — a tablespoonful or more — pure, or mixed with 
mucus. If the growth be small and above the sphincter, the discharge of 
blood is accompanied by no pain ; but if it be large, and especially if it 
be caught within the sphincter, it may give rise to much straining and 
discomfort. In such cases there may be frequent desire to go to stool, 
without the appearance of a dejection ; much mucus is passed from the 
bowel, and the faecal masses may be grooved from the pressure of the 
growth during their passage. If the disease is allowed to go on long un- 
checked, the child becomes pale and cachectic-looking from constant loss 
of blood. 

Diagnosis. — The special form of haemorrhage of the newly-born (nielaena 
neonatorum) is so rare a complaint that in every case where blood is 
ejected from the mouth or passed from the bowel in a very young infant, 
we should rather suspect the blood to be furnished from some extraneous 
source ; and if the child be at the breast, our first care should be to exam- 
ine the nipple of the mother or nurse for fissures or signs of erosion. A 
true haemorrhage in a young baby is at once indicated by pallor of the 
face, sinking of the fontanelle, and depression of temperature. If, after 
bringing up a quantity of bright blood, the child seem contented and 
happy, without loss of colour or any sign of depression or distress, it is 
unlikely that his own body is the source of the bleeding. If, on the con- 
trary, blanching of the face, coldness of the extremities, and signs of gen- 
eral depression accompany or precede the passage of blood, there can be 
no doubt that the haemorrhage is no misleading phenomenon. Still, it is 
often far from easy to ascertain its source. If the bleeding occur at only 
a short interval after birth, and succeed to a prolonged and difficult la- 
bour, or arise in a child in whom the respiratory function has been with 
dimcultv established, we may suspect the phenomenon to be svmptomatic 
42 



658 DISEASE IN CHILDHEN. 

of a congested state of the viscera, aided, probably, by a special hemor- 
rhagic tendency in the child. If it occur some days later, and have been 
preceded by signs of uneasiness after taking the breast, some difficulty of 
deglutition or frequent vomiting, the effusion of blood is possibly due to a 
gastric or duodenal ulcer ; but a positive diagnosis of this lesion cannot 
be ventured upon. If haemorrhage occur solely from the navel, and be 
accompanied by an icteric tint of skin, the case is probably one of con- 
genital deficiency of the bile-ducts. If previous infants in the same family 
have died after presenting similar symptoms, the probabilities are strong 
that this distressing malformation is present. This subject is considered 
elsewhere (see page 717). 

In later infancy and childhood we should inquire about epistaxis, and 
examine the throat and gums for ulceration and signs of recent bleeding. 
If the apparent hematemesis be due to epistaxis, blood will be often seen 
trickling down the back of the pharynx. If the case be one of hemor- 
rhagic purpura, we notice the petechias on the skin, and can detect the 
general disposition to ready effusion of blood. In cases of hemophilia 
the same tendency is probably a well-recognised peculiarity in the family, 
and information as to its existence is usually forthcoming. In the malig- 
nant forms of the specific fevers the accompanying symptoms are usu- 
ally sufficiently characteristic of the nature of the illness ; and, more- 
over, the existence of an epidemic in the neighbourhood is probably well 
known. 

In cases where the hemorrhage is due to a local cause, the source of 
the bleeding may be discovered from the symptoms by which the passage 
of blood has been attended. Small black clots lying at the bottom of a 
thin, dark-coloured water or pea-soup-like fluid, usually indicate ulceration 
of the bowel. Small red clots or streaks are commonly dependent upon 
catarrh of the lower part of the colon, with tenesmus. Red blood in larger 
quantity, pure, or mixed with mucus, and passed with great straining and 
pain, may be possibly due to an invagination of the bowel, or may be the 
consequence of a polypus of the rectum. In cases of intussusception other 
characteristic symptoms are present. If the blood be due to a polypoid 
growth, this may be often seen at the end of defecation caught in the grip 
of the sphincter, and looking like a bright red ball. If the finger is in- 
troduced into the rectum, the polypus can be distinctly felt attached to 
the posterior wall of the bowel by a slender stalk. 

Prognosis. — When hemorrhage occurs in the new-born infant, the 
danger is always great ; but the probabilities of a favourable issue depend 
partly upon the degree of strength of the child himself, and partly upon 
the opinion we have formed as to the source of the bleeding. A well- 
nourished infant of robust constitution can often bear an extraordinary 
loss of blood without sinking under the hemorrhage. A weakly infant 
succumbs quickly. If we have reason to suspect an ulcer of the stomach 
or duodenum, the prognosis is exceedingly unfavourable. Also, if con- 
vulsions occur, if the bleeding continue beyond the first twenty-four 
hours, and if it return after apparent cessation, we have reason to fear the 
worst. Of Lederer's eight cases, five died. Of twenty-three cases collected 
by Rilliet and Barthez, eleven ended in death. Dr. Croom estimates that, 
taking all forms of the disease together, the mortality is about sixty per cent. 
In older children the danger of intestinal hemorrhage depends upon the 
cause to which it is owing, and the severity of the condition of which it 
is the consequence. Rectal polypi are readily removed ; indeed, some- 
times they separate spontaneously and are discharged with a stool. 



GASTROINTESTINAL HEMORRHAGE — TREATMENT. 659 

Treatment. — In cases of melsena neonatorum, the child must be fed 
with his mother's milk given with a spoon, or failing this, with ass's or 
goat's milk, diluted with an equal quantity of barley-water, with whey and 
cream, or with white wine whey. Pancreatised milk, prepared according 
to the directions given in the chapter on Infantile Atrophy, is also very 
suitable. Whatever may be the food, it should be given cold and in small 
quantities at a time. The infant must be kept perfectly quiet. An ice- 
bag should be applied to his belly, and his feet must be kept warm. He 
may take internally a grain of gallic acid, or a couple of grains of the ex- 
tract of krameria, every two or three hours ; or one or two drops of oil 
of turpentine may be given every hour. In addition, four or five ounces of 
the infusion of krameria may be thrown up the bowel. The strength of 
the child must be supported by white wine whey, or by a few drops of 
brandy given at short intervals. 

In older children haemorrhage must be treated according to the condi- 
tion which has given rise to it. Polypus of the rectum is removed by 
seizing the growth with a forceps and passing a silk ligature tightly round 
the pedicle. But in early life the slender stalk often snaps when stretched, 
and the mere action of drawing the polypus below the sphincter often 
detaches it from the mucous membrane. Its separation is followed by no 
bleeding, and haemorrhage ceases from that time. 



CHAPTEE IX. 

ULCERATION OF THE BOWELS. 

The subject of ulceration of the intestinal mucous membrane must, neces- 
sarily, be referred to in describing the various diseases in the course of 
which such ulcerations are liable to arise. Still, it seems desirable, in ad- 
dition, to devote a special chapter to its consideration. It is not uncom- 
mon to meet with ulceration of the bowels in children who have not re- 
cently suffered from acute disease, and in whom no special cause for the 
intestinal lesion can be discovered. Such latent cases are not always easy 
of diagnosis, for ulceration of the bowels is not necessarily attended with 
diarrhoea. Purging, when it occurs, is dependent not upon the ulcerative 
process, but upon the intestinal catarrh which accompanies the breach of 
surface. When the catarrh is at an end the purging ceases, although the 
ulcers may be still unhealed. Typhoid fever in early life often runs its 
whole course without any looseness of the bowels, and this in instances 
where, from the length and severity of the attack, there can be little doubt 
that ulceration has been present. So, also, in cases of scrofulous or tuber- 
cular ulceration of the intestinal mucous membrane, the occasional attacks 
of purging are often separated by considerable intervals during which the 
bowels are sluggish, although, on post-mortem examination of the body, 
extensive breaches of surface are discovered in the intestinal tract. 

Ulceration of the bowels may be acute or chronic. The acute form 
is seen in cases of typhoid fever, dysentery, and inflammatory conditions of 
the bowel which give rise to lesions of the mucous membrane, either by 
the separation of superficial sloughs or by ulcerative inflammation of the 
glandular follicles. If life be prolonged the ulcerative process may pass, 
in certain cases, into a chronic stage, and lead to serious interference with 
the nutrition of the patient. The chronic form of the lesion will alone be 
considered in the present chapter. It occurs in two principal varieties in 
the child, viz. : the simple ulceration from prolonged intestinal catarrh, and 
the scrofulous or tubercular ulceration, which so often accompanies a sim- 
ilar condition of the lungs. 

Morbid Anatomy. — Simple ulceration of the bowels is seen principally 
in infants and the younger children. The part of the bowel affected is the 
large intestine and lower part of the ilium. The ulcers are very shallow, 
and can best be detected by inspecting them sideways. They may be seat- 
ed on the summit of the longitudinal folds of mucous membrane, and are 
then elongated or sinuous. Others are seen between the folds, and are 
small circular breaches of the surface, which can often only be detected by 
careful scrutiny, as their bases are of the same tint as that of the mucous 
membrane surrounding them. The process by which they are formed 
appears to be as follows : — The follicles become enlarged and elevated 
above the surface like little pearly beads. Their contents then become 
purulent, and the follicles still further increase in size. Lastly, the roof of 



ULCERATION OF THE BOWELS — SYMPTOMS. 661 

the follicle is detached and the contents escape, leaving a clean-cut ulcer. 
Mixed up with the ulcers are other follicles — large, elevated, and semi- 
transparent — the contents of which have not yet become purulent. The 
ulcers are roundish or irregular in shape, and vary considerably in size. 
Their edges are well denned and congested, their floor uneven, and of a 
reddish or grayish colour. 

Tubercular or scrofulous ulceration of the bowels is more common in 
children of three or four years old and upwards than in infants. This 
form of lesion is usually associated with scrofulous or tubercular disease 
of the lung, and almost invariably with caseous enlargement of the mesen- 
teric glands. The ulceration appears to be chiefly of a scrofulous nature, 
the presence of the gray granulations being only an occasional and second- 
ary consequence of the caseous degeneration of the follicular structures. 
The seat of the disease is usually the ilium, and the glands affected are the 
follicles of Peyer's patches and the solitary glands, especially those in the 
neighbourhood of the ilio-csecal valve. Primarily, the destructive changes 
are limited to these parts. Thus, the follicles swell up from great multi- 
plication of their corpuscular elements. They then undergo cheesy de- 
generation, soften, and form a number of closely-set ulcers, which unite at 
their borders and give rise to more or less extensive areas of ulceration. 
Their edges are soft, red, and uneven, and their floor red or grayish in 
colour. The ulcerative process does not confine itself to the area of Pey- 
er's patches, but extends laterally along the course of the smaller arteries 
and veins by a similar process of caseation and softening, so as often to 
encircle the gut completely. The infiltration advances into the neighbour- 
ing tissues, and causes gradual disintegration and destruction. At the 
same time the ulcer deepens, but seldom passes beyond the muscular coat. 
As a secondary process gray granulations may appear, and miliary nodules 
are then seen in the tunica adventitia of the smaller vessels, especially the 
arteries and lymphatics. The serous surface at the site of the ulcer is 
opaque and reddened, and may also contain gray granulations. Some- 
times adhesive peritonitis is set up, and neighbouring portions of intestine 
become glued firmly together. If in these cases rupture of the floor of the 
ulcer take place, the intestinal contents are extravasated, not into the gen- 
eral peritoneal cavity, but into a limited pouch formed by the adherent 
bowels. 

The simple form of ulcer may cicatrise and leave little trace ; but this 
termination is less common in the more severe form which is due to a 
tubercular or scrofulous cachexia. Still, even in these cases cicatrisation 
may take place here and there, and on account of the transverse extension 
of the breach of surface, may lead to serious contraction of the channel of 
the gut. 

Symptoms. — Ulceration of the bowels maybe attended by few symp- 
toms, and if, as sometimes happens, diarrhoea is absent, the nature of the 
illness may be completely overlooked. As a rule, the special symptoms of 
the intestinal lesion have been preceded by a prolonged attack of purging, 
which has caused serious interference with nutrition, and greatly reduced 
the general strength. Abdominal pain is not necessarily present, but 
often attacks of pain of a colicky character are complained of, and these 
are usually found to precede the passage of a stool. There may be no ob- 
vious tenderness on pressure of the abdominal wall, but, in many instances, 
deep pressure in the course of the colon seems to give rise to uneasiness. 
Still, even in cases where tenderness appears to be completely absent, 
some tension of the abdominal parietes will be noticed. Indeed, this 



662 DISEASE IN CHILDREN. 

symptom is nearly always present, and careful palpation of the abdomen 
will rarely fail to detect it. The tension is not necessarily general. Often 
it is limited to the side upon which the ulceration exists, as if the muscular 
parietes contracted instinctively to protect the sensitive part from injury. 
The belly is usually more or less distended from flatulent accumulation, 
but this symptom varies in degree. Still, although fuller than natural, it 
appears normal to the eye ; and there is no loss of the natural markings 
such as is seen in cases of peritonitis. If the mesenteric glands are en- 
larged they may be often felt on deep pressure, and the superficial veins 
of the abdomen are then unnaturally visible. 

The appearance of the stools is very characteristic. The bowels may 
not be relieved many times in the day. Sometimes they are even costive. 
In the latter case the stools vary in character. They may consist for the 
most part of light-coloured lumps, often covered with mucus, and some- 
times showing a streak of blood. But every now and again a loose motion 
will be passed which at once discloses the nature of the case. The mo- 
tions which are characteristic of the lesion are of two kinds. The first 
consists of a dark reddish-brown water, intensely offensive and putrid- 
smelling. It deposits a sediment of shreddy, flaky matter, often contain- 
ing little black spots which are minute clots of blood, and sometimes small, 
pale, hard faecal lumps. The second is a pale yellow homogeneous fluid 
of the consistence of cream or thin paste. It often has a curious mucila- 
ginous appearance as the vessel containing it is tilted from side to side. 
This form of stool has, like the first, an offensive smell, but not, like it, an 
odour of putrefaction. 

Haemorrhage from the bowels is seldom copious. Usually it occurs as 
black clots, like little particles of soot ; but sometimes larger black lumps 
may be seen. If there be an ulcer at the lower part of the rectum the 
blood is redder in colour, and may be in larger quantity. The number of 
the stools varies from one or two to twenty, or even more, in the twenty- 
four hours. Their passage is sometimes preceded by slight colicky pain ; 
and if the lower part of the rectum is the seat of ulceration, there may be 
some straining at stool, and the bowel may prolapse. It is not common 
for an ulcer to occupy this part of the rectum ; but should it do so, some 
serious consequences have been noted. The irritation excited by the le- 
sion just within the internal sphincter may cause spasmodic closure of the 
lower outlet, so that much difficulty is met with in evacuating the bowels. 
As a result of this obstruction, great enlargement and hypertrophy of the 
rectum may occur, and we find tympanitic distention of the belly, and 
many of the symptoms of impaction of faeces. 

A child who is the subject of intestinal ulceration is not necessarily 
very thin. The degree to which nutrition is interfered with depends 
upon the amount of intestinal catarrh and consequent diarrhoea. If the 
purging is severe, wasting is rapid ; but if the bowels are not much re- 
laxed, nutrition may go on well, and the child progressively increase in 
weight, although the character of the stools indicates that the ulcers are 
still unhealed. The appetite is often good, and the tongue clean ;. and ex- 
cept for a certain pinched look of the face and distress in the expression 
of the child, he might be thought to be suffering from a very trifling com- 
plaint. Even in cases where the ulceration is of a scrofulous nature the 
same rule holds good, provided the lungs are healthy. Caseous enlarge- 
ment of the mesenteric glands does not necessarily produce wasting ; and 
if the ulceration is not extensive, the temperature high, or the purging se- 
vere, the lesion may produce no noticeable impairment of the child's nu- 



ULCERATION OF THE BOWELS — SYMPTOMS. 663 

trition. The heat of the body is not always increased. I have known 
cases where characteristic stools, containing shreddy matter and blood- 
clots, continued to be passed for months, and where caseous glands could 
be distinctly felt in the abdomen on deep pressure, run their whole course 
and end in recovery, with a temperature which seldom rose above 99°. 

Ulceration of the bowels is sometimes complicated with peritonitis. In 
cases of scrofulous or tubercular ulceration of the bowels, tubercular peri- 
tonitis is a common secondary lesion. But a simple ulceration may also 
be accompanied by inflammation of the serous lining of the abdomen 
without perforation of the bowels having taken place. 

A boy, aged six years, was struck on the abdomen with a heavy piece of 
wood. The accident made him feel faint, and he vomited several times on 
that and the following days. On the day after the injury he complained 
much of pain in the belly, and from that time suffered from frequent col- 
icky pains in the abdomen, and diarrhoea, which often obliged him to keep 
his bed. He was admitted into the East London Children's Hospital six 
months after the accident. At this time the boy was pale, but not very 
thin (he weighed thirty-two pounds twelve ounces). He complained of 
pain in the right side of the belly and over the epigastrium, and there was 
considerable tension of the parietes in these situations. The abdomen 
was rather distended, but was not tender. There was no fluctuation or 
dulness in the flanks, but much gurgling could be felt and heard on palpa- 
tion. His tongue was furred in two lateral bands. The bowels acted four 
times in the day, the stools being pale, small, and solid. The boy had a 
pinched, distressed expression, and seemed languid and dull, but expressed 
himself as quite comfortable except for the occasional pains in the belly. 
There was no albumen in his urine. The lungs and heart were healthy. 
His temperature at 6 p.m. was 99.4°. 

A few days after the lad's admission his temperature rose ; he began to 
vomit, and the bowels became much relaxed. The stools consisted of dark 
brown liquid, or of fluid like pea-soup, with small hard faecal masses. The 
vomiting continued, and the belly became swollen, tympanitic, and very 
tender. The child then rapidly wasted and became exceedingly prostrate. 
Delirium came on, and he sank at the end of a fortnight. During the last 
week his temperature varied between 99° and 102°. 

On examination of the body there were signs of old peritonitis, due 
probably to the accident. In addition, much recent lymph was found coat- 
ing the intestines. In the ilium several of Peyer's patches were found to 
be the seat of ulceration. The ulcers were shallow, with a grayish, uneven 
floor and thickened edges. There were no gray granulations anywhere. 

This boy's condition when he entered the hospital illustrates very well 
the symptoms often found in cases of ulceration of the bowels, for there is 
no reason to suppose that he was then suffering from peritonitis. Abdom- 
inal pain of a colicky character going on for months, especially if combined 
with tension of the parietes, and a history of more or less persistent diar- 
rhoea, is suggestive of intestinal ulcer, and the jrinched, distressed look of 
the boy's face quite excluded the idea that these symptoms were due to 
any unimportant derangement, however persistent. It is an invariable rule, 
which should never be forgotten in clinical investigation, that in a child a 
haggard face means serious illness. However insignificant the symptoms 
and signs may appear, if a child look ill the case is not one to be neglected 
or lightly regarded. The intestinal lesion in this boy was probably the 
consequence of a chronic catarrh of the bowels of many months' standing ; 
for from the time of the accident he continued to suffer from persistent 



664 DISEASE IN CHILDEEjS". 

looseness of the bowels, with attacks of colicky pain. The return of the ca- 
tarrh followed upon the action of an aperient which relieved his bowels of 
a large quantity of hard fsecal masses, and the irritation thus excited no 
doubt induced the second attack of peritonitis from which he died. 

If there is any reason to suspect ulceration of the mucous membrane 
of the bowels, aperients are not to be recommended. Our whole efforts 
should be directed to promote the healing of the ulcers by quieting peris- 
taltic movement. Therefore, however important it may seem to remove 
frecal accumulation, we must remember that an aperient only sets up fresh 
irritation, and that its action may be followed by very serious consequences. 

As a rule, the lower down in the colon the ulceration is seated, the 
more numerous are the evacuations and the more distressing the tenesmus 
and the pain. Still, even if an ulcer occupy the sigmoid flexure or rectum, 
there is not always diarrhoea ; indeed, sometimes the faecal matter presents 
itself only in the form of hard scybala mixed with very offensive muco- 
purulent fluid. In these cases, if haemorrhage occur, it is usually more 
copious, and the blood more natural in colour, than when the ulcers occupy 
any other portion of the bowel. Constipation is most liable to be found in 
cases where the lesion is seated in the small intestine, the colon being 
healthy ; but even in this form of the disease, any additional irritation 
which sets up catarrh and increases the peristalsis of the larger gut may 
give rise to diarrhoea. An ulcer of the duodenum would probably excite 
distressing vomiting and pain at an interval after food. Such a lesion in 
the child has never come 'under my notice. 

Diagnosis. — If the symptoms of ulceration are well marked, there is 
little difficulty in ascribing them to their true cause. An abdomen full, 
without great distention or loss of the natural surface markings ; increased 
tension of the parietes, with tenderness on deep pressure ; diarrhoea, with 
colicky pain, the stools consisting of dark, putrid-smelling, watery fluid, de- 
positing brown or yellow shreddy matter and small black blood-clots— this 
group of symptoms, when combined with a distressed expression of face, 
is very characteristic of intestinal ulceration. The chief difficulty in such 
a case would be to exclude tubercular peritonitis ; for this additional lesion 
might be present without excessive tenderness, without fluctuation, and 
without any caseous lumps being detected on palpation. The belly, how- 
ever, would be more distended and globular ; the natural markings of the 
surface would be absent ; the temperature would probably be decidedly 
febrile ; and in most cases, if the child were laid on his side so as to allow 
of the fluid accumulating in one flank, some evidence of its existence would 
be perceived on turning him rapidly on to his back and immediately pal- 
pating or percussing the part which had been dependent. It is, however, 
fortunately, uncommon to find cases of chronic tubercular peritonitis in 
which the symptoms are so obscure. Usually semi-fluctuation is readily 
discovered, and caseous masses, or unequal resistence of the abdominal con- 
tents, c&n be noticed on examination. 

If the ulceration be accompanied by constipation or solid stools, the 
case may be mistaken for one of faecal accumulation. The colicky pains 
and small lumpy evacuations are very suggestive of this condition, and 
even if the stools are occasionally loose, the symptom is not unknown in 
cases of impacted rectum. A little reflection will, however, convince us 
that there is more in the case than a loaded bowel is capable of explaining. 
We find in most instances a history of previous continued diarrhoea ; if 
tenderness be absent, there is still some tension of the abdominal wall ; 
and the distressed expression of the child's face assures us of the existence 



ULCERATION OF THE BOWELS — PPwOG^OSIS. 665 

of serious disease. Moreover, an examination per anum detects no accumu- 
lation in the rectum, and a copious enema, although it may remove solid 
fjeeal lumps, in no way improves the condition of the patient. 

If we are satisfied as to the presence of the ulceration, we have still to 
decide whether the lesion is of a simple character, or is the consequence of 
a scrofulous or tubercular cachexia. The older the child, the greater the 
likelihood that the ulceration is not simply catarrhal. After the age of 
three years, the manifestations of the scrofulous diathesis become common ; 
and at this age, chronic catarrh of the bowels seldom runs a sufficiently 
persistent course to set up ulceration unless aided by some vice of the 
constitution. If, however, the child have scrofulous or tubercular tenden- 
cies, a much less prolonged irritation of the mucous membrane will give 
rise to caseation and softening in the glandular follicles. The presence of 
enlarged mesenteric glands, chronic lung disease, or other sign of the 
scrofulous constitution, allows us to infer that the intestinal lesion is of a 
similar pathological character. The temperature is not greatly to be relied 
upon in these cases; for it is not necessarily elevated in cases of scrofulous 
ulceration, while it may be raised from accidental causes in the simple form 
of the lesion. Nor is the state of nutrition of much value as a guide ; for 
this depends less upon the nature of the ulcer than upon the degree to 
which catarrh of the bowels may have reduced the strength, and interfered 
with the digestion and absorption of food. If the child show no sign of 
the scrofulous cachexia, if his lungs appear to be healthy, and if tubercu- 
lar peritonitis can be excluded, we may infer the ulceration to be of a sim- 
ple character, although his general strength be poor, and his nutrition un- 
mistakably impaired. 

If the ulceration be tubercular from a secondary formation of the gray 
granulation around the ulcer, and in other parts, nutrition is at once pro- 
foundly affected, and wasting goes on with rapidity. In such a case, all the 
symptoms of general tuberculosis are present, and the child often dies from 
tubercular meningitis. Still, it must be confessed that cases sometimes 
present themselves in which all the symptoms of acute tuberculosis are 
noticed without a single gray granulation being discovered in the body 
after death. The case may even terminate with head symptoms indistin- 
guishable from those of tubercular meningitis, although the interior of the 
cranium appears to be healthy, and the most thorough search discovers no 
gray tubercle in the meninges of the brain. It is difficult to explain these 
cases. Fortunately, they are very exceptional. 1 

Prognosis. — In a case of simple ulceration from prolonged intestinal 
catarrh, recovery will often take place under judicious treatment if there be 
no complication, and if oedema have not occurred. The latter symptom, 
although it is far from indicating that the patient will certainly die, is yet 
of unfavourable import, as it shows a state of great weakness, and weakness 
in itself renders a child less responsive to the action of remedies. 

If the ulceration be scrofulous, the prognosis is still less favourable ; but 
here, if the strength is not greatly reduced, and if other organs are healthy, 
recovery may take place. Caseous enlargement of the mesenteric glands 
does not appear to add to the danger of the case ; but if serious lung mis- 
chief is present, the concurrence of the two lesions leaves us little room for 
hope. If secondary tuberculosis occur, with formation of the gray granu- 
lation in the neighbourhood of the ulcer and elsewhere, death is certain. 



1 A case presenting these deceptive phenomena occurred some time ago in tlio Vic- 
toria Park Hospital, and was published bv Dr. S. West, in the Lancet for September 
BO, 1882. 



666 DISEASE IN children'. 

Treatment. — The utmost care is required in the treatment of these 
cases if the illness is to be conducted to a favourable issue. Our endeavours 
must be directed to quiet irritation ; to prevent the occurrence of fresh 
catarrh ; to reduce peristaltic action, so that the healing of the ulcers may 
not be interfered with ; to support the strength of the patient, and to fur- 
ther cicatrisation by suitable medication. 

The child should be kept in bed in a well-ventilated room, and his 
belly should be protected by a broad layer of cotton-wool confined by 
a suitable bandage. All discharges and soiled linen should be at once 
removed, and every means be employed to keep the air of the room fresh 
and pure. The diet must be regulated so as to convey nourishment with- 
out supplying material for fermentation. As long as catarrh persists, fer- 
mentable food is to be avoided ; and even when the diarrhoea has been 
arrested, the capacity for digesting such a diet still continues small. Milk 
must be positively forbidden ; and starchy matters can only be taken, if 
at all, in very small quantity. An infant must be fed with weak veal or 
chicken-broth and barley-water in equal proportions ; whey, plain, or if 
the child be feeble, made with sherry (white wine whey), and cream ; yolk 
of egg beaten up with whey or veal-broth ; and Mellin's food dissolved in 
either broth or whey, and mixed with barley-water. The meals must be 
small and frequent ; and it is advisable to make constant changes, so as to 
furnish a sufficient variety. If the purging be severe, no more than one 
tablespoonful, or even less, can be given at one meal ; and all food must be 
given cold. 

After the age of eighteen months, raw mutton or beef forms a very val- 
uable remedy. This should be prepared as directed in the treatment of 
chronic diarrhoea, and may be eaten plain or diffused through broth or 
jelly. Uncooked meat so prepared is very nutritious and digestible ; and 
even if not completely digested, the residue appears to be perfectly unirri- 
tating to the bowels. Still, it is well immediately before the meal to give 
a dose of pepsin (gr. iij.— v.) dissolved in a few droi3S of dilute hydrochloric 
acid, in order to aid the process of digestion. If the child be between the 
ages of one and a half and two years, and the purging be severe, little 
other food besides the raw meat, meat-jelly, and broth should be allowed 
for a few days, until the violence of the catarrh is reduced. Afterwards, 
or in older children at first, yolk of egg, well-boiled cauliflower or Spanish 
onion pressed through a fine sieve, and thin well-toasted bread may be al- 
lowed. In some of these cases, where the power of digesting starch seems 
reduced to a minimum, a good substitute for bread is the malted child's 
biscuit made by Messrs. Hill & Sons of Bishopsgate Street. If these 
are objected to, a loaf may be baked expressly for the child in which a pro- 
portion of finely-ground fresh malt is introduced — one part of malt to two 
parts of flour. It is well, also, in addition, to give a spoonful of Hoff's ex- 
tract of malt directly after the meal. When the intestinal catarrh has 
been arrested, milk may be returned to, but should be given cautiously. 
In most cases, it is the curd of the milk which is digested with such diffi- 
culty ; and I have found the pancreatised milk prepared with Benger's 
pancreatic solution, as directed elsewhere (see page 606), to be well borne 
when ordinary milk could not be taken. In other cases, skimmed milk 
seems to agree better than milk from which the cream has not been re- 
moved. Whatever be the age of the child, so long as he is taking milk a 
careful watch must be kept upon the digestive process ; and any sign of 
flatulence or acidity, and especially any return of the purging, should be a 
signal for reducing the quantity of the milk, or even for omitting it for a, 



ULCERATION OF THE BOWELS — TREATMENT. 667 

time altogether from the diet. If the child is weakly, or appears to be ex- 
hausted by the purging, stimulants must be given as required. White 
wine whey for infants, and brandy-and-e gg mixture for children of all ages, 
are the most valuable. 

With regard to medicines : — As long as there is purging, astringents 
with opium are indicated. It is well in these cases not to rely too much 
upon one form of remedy, for we shall often be forced to make frequent 
changes in the prescription in order to guide the disease to a favourable 
ending. If the stools consist of the homogeneous, pasty liquid matter 
which has been described, nitrate of silver is pre-eminently useful. One^- 
eighth to one-fifth of a grain should be combined with a few drops .of di- 
lute nitric acid, and one or two drops of laudanum, in water sweetened 
with glycerine. This dose can.be given three times a day. If from tenes- 
mus, pain in the right iliac fossa, or the appearance of bright blood in the 
stools, there is reason to believe the large bowel to be the seat of the le- 
sion, internal administration of the drug may be supplemented by the use 
of the salt locally. For a child two years of age, the lower bowel should 
be first cleared out by a copious injection of tepid water, and afterwards 
two grains of the nitrate dissolved in four ounces of water must be thrown 
up the bowel through a long tube. If tenesmus is urgent, five drops of 
laudanum may be added to the medicated injection ; or, after the return 
of the nitrate, the laudanum, mixed with half an ounce of thin warm starch, 
may be thrown into the bowel. The astringent injection can be repeated for 
three or four nights in succession, and can then be given only on alternate 
nights, if the symptoms still persist. Instead of the silver salt, sulphate of 
copper (half a grain to the ounce of water) may be used for the injection, and 
is often of service. This treatment by injections is useful not only by ap- 
plying the astringent directly to the affected part, but also by clearing away 
hardened lumps of faecal matter, which are very apt to be retained and keep 
up irritation even when the stools generally are loose and frequent. 

Another useful remedy is the extract of hsematoxylon. Three to five 
grains may be combined with one or two drops of laudanum, and two to 
four drops of ipecacuanha wine in the compound chalk mixture, and given 
three times in the day. A combination of the extracts of hseniatoxylon 
and rhatany (gr. iij. of each) is often found of signal efficacy if the purging 
is obstinate ; or gallic acid (gr. ij.-v.), with a few drops of aromatic sul- 
phuric acid, may be used. Opium should be always added to the astrin- 
gent, whatever this may be, in order to reduce irritability of the mucous 
membrane, and quiet peristaltic movement. Sometimes we find cases, 
which have resisted all other treatment, yield to bismuth given in large 
doses. For a child of two years old, fifteen grains of the carbonate of 
bismuth may be given with five grains of the aromatic chalk powder, every 
four hours ; and a few doses of this combination is followed by really sur- 
prising improvement in many cases. If thought desirable, a drop of 
laudanum may be added to each alternate dose of this remedy, or a small 
injection of starch and opium may be given every night. 

When purging has been arrested, the healing of the ulcers may be pro- 
moted by perfect rest, and the administration of the pernitrate of iron 
(TTj, iij.-v.) with laudanum (TT|, j.-ij.) in a teaspoonful of water sweetened with 
glycerine ; or quinine may be given with pepsin and strychnia, as recom- 
mended during convalescence from inflammatory diarrhoea. For a con- 
siderable time it will be necessary to pay strict attention to the diet, and 
limit the quantity of farinaceous and saccharine foods ; and long after 
convalescence is established, the child should continue to wear a flannel 
bandage round the belly as a necessary part of his dress. 



CHAPTEE X. 

INTESTINAL OBSTRUCTION (INTUSSUSCEPTION). 

Occlusion of the intestine in the child is rarely due to any other cause 
than intussusception or invagination of the bowel. Although any form of 
mechanical obstruction met with in the adult may conceivably arise in the 
young subject, such lesions are so uncommon in early life that when dis- 
covered they have been placed upon record, less for their practical useful- 
ness, than for the interest they may possess as pathological curiosities. 
Thus, the bowel has been known to be strangulated by peritoneal bands, 
or by the vermiform appendix ; to be obstructed by carcinomatous or 
lymphatic swellings ; or to be narrowed by congenital strictures. The 
temporary impaction of faecal matters which is sometimes found, is treated 
of elsewhere (see Constipation). A description of intestinal obstruction in 
the child practically resolves itself, then, into a description of intussuscep- 
tion, and the present chapter will be confined to this subject. 

Causation. — Invagination of the bowel, although an uncommon ac- 
cident at any period of life, is more often seen in the young child than in 
the adult. Babies seem to be especially prone to it, for a large proportion 
of the cases occur during the first twelve months of life. This compara- 
tive frequency of the lesion in infancy is attributed by Rilliet to the looser 
connections of the caecum in the iliac fossa at this age, and also to the im- 
perfect development of its muscular bands, which lessens its resistance to 
the penetration of the small intestine into its interior. 

In infancy, intussusception consists either of an invagination of the 
small intestine into the larger, or of one portion of the colon into another 
portion. At a later period of childhood, the intussusception may involve 
the small intestine alone, without the larger gut being concerned in the 
invagination. 

Infants and children in whom this accident occurs, are usually sturdy 
and well nourished ; and the illness takes places suddenly, as a rule, with- 
out being preceded by a period of feebleness or a state of ill-health. 
Boys are more subject to it than girls. The causes which give rise to it 
are not always easy to determine. Drastic purgatives, indigestible food, 
violence of cough, external injury, and even rapid motion, as when a child 
is danced quickly up and down in his parents' arms, have all been quoted 
as exciting causes of the lesion. It is certainly curious to find that in 
many of these cases the symptoms of obstruction were immediately pre- 
ceded by a fall or other accident. In a case which lately came under my 
own notice — an infant of ten months old — the first symptoms followed a 
fall from his mother's bed on to the floor. Indeed, the child, when first 
seen, had a severe bruise on the temple and cheek, testifying to the severity 
of the accident. Still, if causes such as these were alone capable of de- 
termining involution of the bowel, the accident would be surely more 
commonly met with than it is. In some recorded cases, intussusception 
has been preceded by intestinal catarrh; and it is conceivable that any 
sudden increase of peristaltic action may help to induce it. 

Morbid Anatomy. — In intussusception, one portion of the bowel is 
forced or invaginated from above downwards into another portion imme- 
diately continuous with it. At the point of invagination, therefore, a swell- 



INTUSSUSCEPTION — MORBID ANATOMY. 669 

ing is seen which consists of three thicknesses of gut disposed one over 
another. Firstly, the external investing tube ; secondly, a portion con- 
tinuous with this, which has been doubled inwards, or inverted within the 
first ; lastly, the contained portion of the bowel whose entrance into the 
first constitutes the lesion. Of these, the middle layer, which is of course 
reversed or turned inside out, has its mucous coat, now on its exterior, in 
contact with the mucous coat of the investing portion of the gut ; while 
its peritoneal coating, now innermost, is in contact with the peritoneal cov- 
eriDg of the contained or invaginated portion of the bowel. 

The intussusception is formed not only by the intestinal tube, but also 
by the portion of mesentery in connection with it. This being drawn in 
with the invaginated portion, presses the latter to one side. Consequently, 
the foremost opening of the contained segment is not in the middle line, 
but is twisted so as to rest against a part of the investing sheath. When 
once started, the invagination tends to increase by peristaltic action, the 
increase being always at the expense of the outermost portion, and may 
vary in degree from an extent of a few inches to several feet. 

The consequences of the intussusception are occlusion of the intestinal 
canal, and obstruction of the circulation in the double layer of bowel 
which forms the invaginated portion. The two inner tubes become dark 
purple from congestion, and swollen ; and some effusion mixed with blood 
is poured out between the opposed mucous surfaces, and also into the 
canal beyond the point of obstruction. Lymph is afterwards exuded, and 
the opposed serous surfaces become adherent. In some rare cases, the 
inflammation extends beyond the seat of disease, and causes general peri- 
tonitis ; in others, ulceration and perforation take place in the investing 
sheath, owing to irritation of the end of the contained portion ; and this is 
sometimes seen to protrude through the opening thus formed, into the 
cavity of the peritoneum. If the strangulation of the invaginated portion 
is complete, it becomes gangrenous, and, in favourable cases, may be de- 
tached, piecemeal or in mass, and discharged through the anus. Should 
this happen, if the adhesions already formed remain firm, the sheath or 
invaginating segment, being united at its free end with the part of the 
bowel immediately above the point of intussusception, still forms with it a 
continuous tube, although the intervening portion has been removed. 
Sometimes, however, the adhesions give way, and then extravasation may 
take place into the peritoneum. 

In infancy, it is usually the small intestine which becomes invaginated 
into the colon. The end of the ilium, with the ilio-csecal valve, is forced 
into the caecum. This, as the intussusception increases, penetrates farther 
and farther into the colon, drawing behind it the ilium, and doubling first 
the caecum, then the ascending colon, and afterwards more and more of 
the larger bowel the farther it extends. At last, it may reach the rectum, 
and be felt by a finger introduced through the anus. In such a case, when 
the abdomen is opened, the larger bowel seems in great part to have disap- 
peared, and a tumour is found occupying, usually, the left side, often the 
iliac fossa. This is of a slate-gray colour, is elongated in shape, and 
doughy to the touch. By traction, the invaginated portion can be drawn 
out, although it is usually soft, and is apt to tear in the process. Before 
penetrating into the colon, the ilium may or may not pass through the 
valve ; usually, it does not do so, and if a portion pass between the lips of 
the valve, it is seldom more than a few inches. 

Sometimes, even in infancy, more often in older children, the intussus- 
ception occurs in the course of the small intestine, the colon taking no 



670 DISEASE IN CHILDREN". 

part in the invagination. When this displacement occurs in a healthy 
child, it of course gives rise to symptoms of obstruction. It may, how- 
ever, take place without producing symptoms. In examining the bodies 
of children, especially if they have died of intestinal catarrh, or of some 
form of brain disease, it is not uncommon to find portions of the bowel 
invaginated, often in several places, without any symptoms of this accident 
having been noticed during life. This form of intussusception usually oc- 
curs in the small intestine. It is supposed to take place immediately be- 
fore death ; for the bowel is merely invaginated, and is not swollen or con- 
gested, or altered in appearance in any way. Moreover, it can be readily 
drawn out by a very slight effort. 

Symptoms. — There is some variety in the symptoms, according to the 
age of the child and the seat of the invagination. In infants the intussus- 
ception is almost always at the expense of the larger bowel. In older 
children it may be confined to the jejunum or ilium, without involving 
the colon. The symptoms noticed in infants, and those arising in older 
children, must be therefore considered separately. 

In the case of an infant the ordinary history given by the mother is 
that the baby was in his usual health, when suddenly he gave a scream, 
turned excessively pale, and then cried violently, writhing and drawing up 
his legs as if in great suffering. The pain is not constant, for the child, 
after a time, ceases to cry, and lies back, looking pinched and pale ; but in 
a short time the paroxysm returns, and he screams and writhes as before. 
When the pain first comes on, the infant vomits his last meal, and the 
vomiting is usually repeated, especially if food or medicine be given to 
him. In most cases, an aperient is at once ordered, and is returned di- 
rectly it has been swallowed. The state of the bowels is important. If 
they are empty below the point of obstruction, they remain obstinately 
confined, and the straining efforts, which are usually made, merely expel 
mucus and blood. If the lower bowel contains any faecal matter, this is 
discharged in a thin, loose state, shortly after the occurrence of the intus- 
susception. The stool may contain blood, and the action of the bowels is 
usually followed, after a short interval, by further straining and the evacu- 
ation of mucus and blood. At this time, the temperature is not elevated ; 
the belly is painless— indeed, during the paroxysms of colic, gentle frictions 
to the belly seem to afford relief ; the abdomen is neither full nor tense, 
and between the attacks of pain, the child may be often found in his cot 
lying upon his belly. Sometimes the secretion of urine is greatly dimin- 
ished, but this is a very variable symptom, and apparently has no refer- 
ence at all to the seat of obstruction. Often, at this period, the most 
careful examination of the belly detects no localised swelling ; but after 
a time, if the abdomen be carefully palpated during an interval of rest 
from pain, a distinct swelling may be perhaps detected by the fingers 
pressed deeply into the left iliac fossa. There may be some tenderness at 
this point if some hours have elapsed since the occurrence of the accident. 
Later, the mass can often be reached by the finger introduced into the 
rectum, for its tendency is to travel farther and farther down the bowel. 
The child sleeps but little after the invagination has occurred. If, at the 
first, he sleeps between the attacks of pain, he soon ceases to do so, and re- 
mains wakeful and restless, constantly whining and crying until exhausted. 
The temperature varies. Sometimes it is little altered from the normal 
level. In other cases, it begins to rise after a few hours, and may reach 
102° or 103°. Directly symptoms of collapse are noticed, the tempera- 
ture usually falls below the level of health. 



INTUSSUSCEPTION — SYMPTOMS. 671 

The course of the illness is apt to vary according to the degree of 
strangulation of the invaginated segment, and the more or less complete- 
ness of the obstruction to the passage of the contents of the bowel. In rare 
cases, the passage is not completely occluded, so that fsecal matter can 
still make its way, although, of course, in small quantity, through the 
narrow channel. The constipation is then not obstinate, but the stools are 
scanty, and consist more of mucus and bloody fluid than of the ordinary 
constituents of an evacuation. 

The symptoms continue without improvement. The pains return at 
intervals. The child, in some cases, turns away from his bottle ; in others, 
he sucks greedily to assuage his thirst ; but, whether he swallow willingly 
or not, the effect is the same, and he usually vomits almost immediately. 
If he vomit at other times, the ejected fluids consist of bile-stained mucus, 
and very rarely of fsecal matter. The face gets pale and more haggard ; 
the eyelids close incompletely, and the eyeballs are sunken. Occasionally 
he strains, but only blood and mucus escape from the rectum. His belly 
is often tender over the seat of the tumour, and may become fuller and 
more tympanitic, with some tension of the parietes. Sometimes the 
sphincter is relaxed and open. 

The symptoms of collapse come on early if the obstruction of the 
bowel is complete, and usually, on the third day, the child is found in the 
state described. Unless general peritonitis occur, there is seldom much 
pyrexia ; indeed, the child, as a rule, feels cold and damp ; and even if the 
internal temperature is higher than natural, the extremities feel cold. In 
this state, he remains until he dies. A convulsive seizure may precede 
death, and sometimes convulsions occur in the course of the illness, and are 
repeated several times. Before death, the invaginated mass may be perhaps 
seen to protrude for an inch or two outside the anus, as a dark-coloured, 
elongated lump. This, however, is not common. When the strangulation 
is complete, the disease seldom lasts longer than a week, and death often 
occurs in three or four days. If the obstruction is not complete, the prog- 
ress of the case is longer ; scanty loose motions may be passed at inter- 
vals, and the child often lingers for a fortnight or more. 

If, by any means, the invaginated portion of the bowel can be returned, 
the vomiting ceases ; the bowels discharge a copious, semi-fluid, offen- 
sive stool, and the child sleeps. On waking, he takes the bottle or the 
breast, and seems cheerful and contented, although necessarily languid and 
feeble. 

In older children, the symptoms correspond, in the main, with those 
already described, but certain differences are noticed. Thus, the disten- 
tion of the belly is usually greater after the age of infancy, and comes on 
earlier. It is sometimes extreme, and the coils of dilated intestine can be 
made out through the abdominal parietes. Also, vomiting is generally 
persistent, and is apt soon to be feculent. The child will take no food, 
but is excessively thirsty. The discharge of blood from the anus occurs 
less frequently the more advanced the age of the child. If the invagina- 
tion occupy the large intestine, the strangulated portion of the bowel is 
approached near to the outlet, and haemorrhage from the ruptured vessels 
is likely to take place. If, however, the intussusception is higher up, and 
is confined to the small intestine without implication of the colon, no haem- 
orrhage at all may be noticed. There is then, in most cases, obstinate con- 
stipation. When the stage of collapse comes on, the tongue becomes dry, 
and is covered with a brown fur ; the belly is tympanitic ; the eyes are 
sunken, and the face of the child is ghastly and death-like. 



672 DISEASE IN CHILDREN. 

If separation and elimination of the gangrenous portion of the bowel 
takes place, this favourable change is usually noticed in the course of the 
second week. In these fortunate cases, the dark-coloured gangrenous seg- 
ment of the intestinal tube is passed with much straining, and often a quan- 
tity of dark, offensive feculent matter comes away with it. The amount of 
this varies, and is often very considerable. The discharge is followed by 
symptoms of great relief. The child usually falls into a profound sleep 
from which he wakes greatly refreshed. His thirst is diminished, lus appe- 
tite begins to return, and his whole aspect betokens great improvement. 
The gangrenous portion may not be expelled in one piece, but sometimes 
comes away in patches and shreds, mixed with foul-smelling faeces and 
blood. After the separation and discharge of the slough, recovery usually 
follows with great rapidity. 

In the fatal cases, death results more often from collapse than from peri- 
tonitis. The child becomes weaker and weaker, and dies from asthenia. 
Sometimes death is preceded by a convulsive seizure. 

The above is the course of the disease in infants and older children. 
Of the symptoms, the sudden occurrence of severe abdominal pain, the 
vomiting, the constipation, the discharge of blood from the bowel, and the 
discovery of a swelling by palpation of the belly or exploration per anum, 
are the most characteristic. 

The pain is of an excruciating character, as is shown by the child's 
agonising cries, his restless, jerking movements, and the death-like pallor 
which spreads over his face. In a case recorded by Dr. Wilks, the infant 
actually fainted from the intensity of his suffering. The pain comes on in 
paroxysms, but these do not occur at regular intervals. Often, after the first 
access, the colic suddenly ceases, and the child appears to be easy. He may 
remain free from pain, showing no sign of illness, for some hours, but sooner 
or later the paroxysms return. This is most often the case with infants. 

Vomiting is always present, and may vary from mere regurgitation to 
violent retching. It is often accompanied by hiccough. The vomited mat- 
ters consist of food and medicine, or, if nothing has been taken, of mucus 
and bile. Occasionally, blood is thrown up from the stomach. Mr. Macleod 
has recorded the case of a male infant, aged six months, in whom this symp- 
tom was noted before death. The intussusception had occurred in the 
usual situation for this age. 

Constipation is not a constant symptom. If the bowel below the point 
of obstruction contains fsecal matter, this is invariably expelled early. 
There is then no alvine discharge for the remainder of the illness. In less 
common cases a certain amount of diarrhoea may be present, if the strangu- 
lation of the bowel is not complete ; for the swelling of the invaginated 
segment becomes reduced after a few days, and the calibre of the canal 
may be partially restored. 

A discharge of blood and mucus is one of the most constant symp 
toms. The amount varies. In some cases, it may be scanty, nothing more 
than a stain of blood being seen upon the diaper when the napkin is changed. 
In other cases, the quantity may reach several ounces. It appears early. 
It may be seen at the time of the first effort of vomiting, and is seldom de 
layed longer than twelve hours. In infants, this symptom is almost invari- 
ably present, and may be taken to indicate a degree of constriction of the 
bowel stopping short of actual strangulation and complete arrest of circu 
lation. In older children, as has been said, it may be wanting. 

A distinct swelling in the course of the bowel, when discovered, is a| 
valuable diagnostic sign ; but often it is not present. The tumour gener 



INTUSSUSCEPTION — SYMPTOMS — DIAGNOSIS. 673 

ally lies in the left iliac region, and gives a firm, doughy sensation to the 
finger. It is movable, and varies from a walnut to a hen's egg in size, or 
may even be larger. When detectable by palpation of the belly, the tu- 
mour can often be reached by the finger introduced into the rectum ; espe- 
cially if at the same time pressure is made upon the invaginated mass by 
the other hand placed upon the abdomen. A rounded lump, feeling very 
much like the cervix uteri in a vaginal examination, may then be felt by the 
point of the finger. Sometimes the mass can be seen to protrude beyond 
the anus, but this is exceptional. Out of forty-nine cases collected by Dr. 
Lewis Smith, the protrusion occurred only in six. 

Tenesmus is usually present, and is often distressing. It may cease as 
the child's strength becomes reduced. 

The amount of fever varies. At first, the temperature is normal, but as 
inflammation occurs in the intussusception, the bodily heat increases, al- 
though it is rarely excessive. The symptom is said to be less marked in 
infants than in older children. The pulse, after the first few days, is very 
rapid, and as the strength declines, becomes excessivelv frequent and fee- 
ble. 

The duration of the illness varies, as has been said, according to the 
completeness of the strangulation of the bowel, and also according to the 
age and strength of the child. In infants, it rarely lasts longer than a 
week, and death often takes place as early as the fourth or fifth day. In 
older children, the course of the disease may be equally rapid ; but often 
it is more protracted, and cases have been recorded in which the lesion 
has become chronic, lasting several months. Separation and elimination 
of the gangrenous portion is never seen in infancy, and is rare even in 
more advanced childhood. 

Diagnosis. — When a child who has been previously in good health, or 
has suffered merely from looseness of the bowels, is suddenly seized with 
violent paroxysmal colic and repeated vomiting, followed immediately, or 
after a few hours, by evacuations consisting of non-faecal mucus and blood, 
discharged with great straining, we may conclude that he is suffering from 
occlusion of the bowels, due, in all probability, to intussusception. The 
discovery of an oval tumour, in the left side of the belly, will confirm us in 
our opinion, and if we can succeed in touching the mass, by the finger in- 
troduced into the rectum, the sign is a conclusive one. The conjunction 
of all the above symptoms is of importance, and the absence of any one of 
them is not to be disregarded. Thus, if we are called to a child who has 
been taken suddenly with pain in the belly, and vomiting, and whose bow- 
els are obstinately confined, we must not conclude too hastily that an intus- 
susception has occurred. The pain may be extreme and paroxysmal ; the 
vomiting frequent and distressing; and the constipation may have resisted 
aperients and enemata, without obstruction of the bowels in any form be- 
ing present. Peritonitis, which paralyses the bowel, and induces vomiting 
by reflex disturbance, may produce just such symptoms. On the other 
hand, a passage from the bowels may take place, although intussusception 
has actually occurred. The appearance of one loose faecal stool, after the 
beginning of the illness, is common in intussusception, for the contents of 
the colon below the point of obstruction are usually expelled shortly after 
the occurrence of the invagination. If, however, the bowels continue loose, 
and faecal matter is afterwards evacuated, whether by injection or other- 
wise, the symptom is not in favour of intussusseption ; for, even if the chan- 
nel become pervious later, after swelling has partially subsided, it is rarely 
free during the first two or three days of the illness. In such a case we 
43 



674 DISEASE IN CHILDREN. 

should hesitate to ascribe the symptoms to invagination of the bowel, un- 
less the other evidence in its favour points irresistibly to such a conclusion. 

Again, severe colic in a young baby is often accompanied by alarming 
symptoms, in which all the signs of the most violent pain may be followed 
by great prostration. In the attack, the child utters piercing screams, and 
writhes his body exactly as he does in intussusception ; indeed, in almost 
all cases of invagination of the bowel, we generally find that an aperient 
has been ordered, under the impression that the spasms of pain are the con- 
sequence of irritation of the bowels by undigested food, or flatulent disten- 
tion. In every case, therefore, where intussusception is possible, we must 
weigh the evidence very carefully, as the recovery of the child may depend 
upon early and accurate diagnosis of his illness. In addition to simple 
colic and peritonitis, intussusception may be confounded with dysentery, 
with impaction of hardened faecal masses, and with intestinal haemorrhage 
from other causes. 

In simple colic the pain, although often excessively severe, is not paroxys- 
mal, with complete remissions, and usually ceases with the expulsion down- 
wards of a quantity of gas. The skin is often hot, and the belly hard and swol- 
len. There is no vomiting or tenesmus, or discharge of bloody mucus from 
the bowels. It is very important to attend to these points, for the adminis- 
tration of castor-oil or other aperient, which quickly cures an ordinary colic, 
cannot but be injurious in a case of intussusception, increasing the peris- 
taltic action of the bowels, and aggravating the invagination. 

Between peritonitis and actual obstruction of the bowels, the diagnosis 
is often very difficult. The form of peritonitis which is most apt to simu- 
late intussusception, is that in which inflammation occurs suddenly as a 
consequence of ulceration and perforation of the vermiform appendix, with 
extravasation into the peritoneal cavity. In these cases, symj)toms similar 
to those of obstruction may come on quite suddenly, and be very severe. 
But in peritonitis, the temperature is always elevated from the first ; the 
abdominal parietes are distended and tense, and pressure in the right 
iliac fossa is painful. In intussusception there is no pyrexia at the first ; 
the abdominal wall is lax and undistended ; there is frequent tenesmus, 
and, after a few hours, blood and mucus are discharged from the bowel. 
This last symptom, added to the signs of intestinal occlusion, is pathogno- 
monic. The mistake is most likely to be made when the symptoms occur 
in a child after the age of infancy, and haemorrhage is not present, or is 
slow to appear. Still, even in these cases, the absence of fever, the lax- 
ness of the parietes, and the tenesmus should raise strong suspicions of 
the real nature of the disease. In all cases of doubt, a careful examina- 
tion of the belly, while the child is under the full influence of an anaes- 
thetic, will usually enable us to detect the presence of a tumour in the 
abdomen if invagination has occurred. 

It is possible to mistake intussusception for dysentery, for the mistake 
has actually been made. In the latter disease, the dejections are often 
small, and consist of thick mucus, mixed more or less intimately with 
blood. They are discharged with great straining and pain. Even in, 
severe catarrh of the lower bowel, which is often improperly called "dys-| 
entery," much mucus, and often streaks or spots of blood, can be observed. 
But these symptoms alone are far from being characteristic of intestinal I 
invagination. We miss the abrupt onset, the frequent vomiting, and the 
lax, undistended condition of the belly. Moreover, the whole course of thel 
two diseases is different, and true dysentery is usually an epidemic malady. 

In cases of impaction of /cecal matter — an accident which constitutes 



INTUSSUSCEPTION— PROGNOSIS— TREATMENT. 675 

real occlusion of the bowel — the symptoms of invagination may be closely 
simulated. Vomiting, colicky pain, tenesmus, and constipation may all be 
present, and on examination of the belly, a firm tumour may be detected 
through the abdominal parietes. But in fsecal accumulation, there is usu- 
ally a history of hard and scanty stools for a considerable period before 
the attack ; the vomiting is much less severe, there is no bloody mucus 
evacuated from the bowels, and the tumour is more superficial, does not 
shift its place, and can be indented by firm pressure with the fingers. If 
this condition be suspected, a large purgative enema will cause the tumour 
and consequent symptoms to disappear. 

Sometimes, in intussusception, the amount of blood discharged from 
the bowel is very copious. Still, the other symptoms of invagination are 
present, and it is only necessary to be aware that hemorrhage may be oc- 
casionally profuse, to prevent this fact from casting any doubt upon the 
correctness of the diagnosis. 

If attention be paid to the symptoms which have been pointed out as 
characteristic of intussusception, we shall be able, in most cases, to arrive 
at a correct conclusion. An examination per anum should never be neg- 
lected ; nor, in a doubtful case, should we omit to inspect the ordinary sit- 
uations of rupture, for although strangulated hernia is rare in young 
subjects, it does, occasionally, occur. 

Prognosis. — When we have satisfied ourselves of the presence of intus- 
susception, the prognosis is excessively grave. In the young baby, in 
spite of a few recorded cases of spontaneous reduction of the invaginated 
portion of the bowel, and of others in which remedial measures promptly 
applied proved successful, any measures we may resort to must be under- 
taken with serious forebodings. The danger is in direct proportion to 
the urgency of the symptoms. If the acuteness of the case indicates tight- 
ness of constriction, the prognosis is most serious, whatever measures are 
adopted, and however quickly assistance is rendered. In almost all cases 
of successful reduction by taxis, inflation, or injection, the symptoms have 
not been very severe. To be successful, treatment must be early ; but 
delay is less fatal if the constriction be only moderate, than when strangu- 
lation is complete. If the infant is seen after the end of the third day, 
and acute symptoms have undergone no alleviation, a fatal issue to the 
illness can hardly be doubted. 

In older children, whose superior strength enables them to resist for a 
longer period the prostrating effects of the obstruction, recovery by slough- 
ing and discharge of the invaginated segment is possible, and may even take 
place when the child is in extremis, and after all hope has been abandoned ; 
but this is a result which in any individual case we can never dare to an- 
ticipate. Certainly, there are no indications by which so favourable an issue 
can be foretold. Even if the evacuation of the slough by stool shows that 
elimination has actually been accomplished, we must still not be hasty in 
declaring the danger at an end ; for the greatest care will yet be required 
during the period of convalescence to prevent the newly-formed adhesions 
from being injured or detached. 

Treatment. — Accuracy of diagnosis, and especially early recognition of 
the nature of the complaint, are of great importance in this disease. If the 
real cause of the vomiting and colic are discovered at the beginning, remedial 
measures may be applied with greater hope of success. As it is, medical 
advice is seldom sought until the bowel has been irritated by one or more 
doses of aperient medicine, to the serious aggravation of the patient's con- 
dition and the lessening of his chances of recovery. 



676 DISEASE IN CHILDREN. 

The only admissible remedy is opium. This should be given at once, 
and repeated as often as is necessary to lull the pain, and keep the child 
under the influence of the narcotic. It is best given by subcutaneous in- 
jection, and may be usefully combined with atropine. It is well to begin 
with small quantities, although it will be generally found that the system, 
even in infancy, is singularly tolerant of the drug. For a child of twelve 
months old, one-twentieth of a grain of morphia and a sixth of a grain of atro- 
pine may be used every half-hour until some sensible effect is produced upon 
the symptoms. This not only relieves the suffering of the patient, but also 
tends to prevent any increase in the invagination and to check the vomiting. 

If the case is seen sufficiently early, the question of endeavouring to re- 
duce the invagination by mechanical means must be considered. Mechan- 
ical interference is only allowable during the first few days of the illness, 
before exudation of lymph has caused adhesion between the serous sur- 
faces ; and will be useless if great tenderness on pressure of the invaginated 
mass indicates the presence of inflammation. The means employed may be 
taxis, insufflation of air, or the injection of water. Before proceeding to any 
of these measures, the child, unless a young baby, should be placed under 
the full influence of an anaesthetic. Taxis consists in kneading and other- 
wise manipulating the abdomen with the hand. This method is generally 
employed in conjunction with either of the others. The child is laid upon 
his back with the nates raised so that the body is inclined at an angle of 
45 degrees. A large quantity of tepid water is then injected very slowly 
into the bowel by a Davidson's syringe capped with a long tube. Every 
now and again the abdomen must be kneaded with the hand so as to work 
the fluid along the bowel upwards towards the obstruction, and this process 
of taxis may be continued for several minutes. As much fluid must be used 
as the bowel can be made to contain. The best proof that reduction has 
been effected is sleep. As a rule, directly the child's more pressing symp- 
toms are relieved, he sleeps at once. The return of the invaginated bowel 
is also sometimes marked by a discharge of blood and mucus, followed by 
a copious, offensive, semi-fluid stool. 

Insufflation of air is best suited to cases where the intussusception has 
descended into the rectum and an enema returns at once. The air may be 
supplied by a common bellows, to the nozzle of which a caoutchouc tube 
has been attached, terminating in a long gum-elastic tube. Some lint mast 
be wrapped round the base of this tube to enable it to fit closely within the 
sphincter. Air must be injected slowly, and at times the belly should be 
manipulated as in the former case. The process should be continued un- 
til the large bowel is thoroughly distended with air, if this prove possible. 
In a favourable case, the mass will be felt to recede from the left iliac region, 
and then pass altogether from the reach of the finger. If this happen, we 
may have great hopes of having achieved our object. 

These measures can only have a chance of success during the first three 
days. Certainly, after the fourth we can do nothing but harm by distend- 
ing the bowel with either air or water. 

In addition to the above methods, attempts have been made to replace 
the bowel by a long sound passed into the rectum, and have occasionally 
succeeded. This method is, of course, only applicable to cases where the 
invagination is within easy reach of the outlet. An eesophageal bougie with 
a sponge fastened to its end forms a useful instrument for this purpose. 
If the above measures prove ineffectual, it becomes a question whether a sur- 
gical operation should be resorted to, or whether we should trust merely 
to complete rest and opium. 



INTUSSUSCEPTION — TREATMENT. 677 

The operation of opening the abdomen and reducing the invagination 
with the fingers has been happily accomplished in some cases, and may offer 
a chance of success when other means have failed. Our decision as to its 
desirability will depend upon the opinion we have formed with regard to 
the tightness of constriction of the invaginated gut. As Mr. Hutchinson 
has pointed out, the imprisoned portion of the bowel may be tightly stran- 
gulated, or merely irreducible, with comparatively little constriction. In the 
former case, the course of the disease is very rapid, and the symptoms are 
severe ; gangrene quickly supervenes, and death is speedy. In the latter, 
where the channel often remains pervious, although much narrowed, the 
course is more chronic, and the symptoms are less pressing. It is in these 
slower cases that the operation is especially likely to be successful. Un- 
fortunately, the difficulty of judging of the degree of tightness of the con- 
striction is very great. The severity of the symptoms is not always, in chil- 
dren, a trustworthy guide. Much depends in such a case upon the nervous 
impressibility of the particular patient ; for a degree of strangulation which 
in one child will produce violent vomiting and early prostration, will, in an- 
other, be attended by much less serious and urgent symptoms. In young 
babies, unless the operation be performed within the first three days, and 
before the occurrence of collapse, we can have little hope of its success ; but 
as, in such cases, the death of the child, if left alone, is certain, the operation 
is surely a permissible one. In older children, I am strongly of opinion that 
it should not be performed if, from violence of vomiting, severity of the gen- 
eral distress, and early occurrence of prostration, we have reason to believe 
the strangulation of the bowel to be complete. The gut would probably 
be found either gangrenous or adherent. In such cases there is always the 
last chance of sloughing and elimination, and this the operation would take 
away. On the other hand, if the general symptoms are comparatively mild, 
and especially if the intestinal channel is not completely occluded, the oper- 
ation is distinctly called for after failure of other means of reduction. 

In the early period of the illness, vomiting is often encouraged by re- 
peated and unnecessary feeding of the child. At this time, it is best to give 
no food at all, and only to allow an occasional spoonful of barley-water to 
assuage the thirst. If old enough, the child may be allowed to suck lumps 
of ice. If the vomiting remits, some simple food — milk and barley-water 
for a baby, given cold with a teaspoon ; and for an older child, strong beef- 
tea, essence of meat, and milk, also in small quantities at a time — may be 
allowed. When the strength begins to fail, brandy-and-egg mixture can be 
given. 

If elimination of the gangrenous segment take place, the utmost care 
should be observed that for months afterwards the child eat sparingly of 
farinaceous and fermentable articles of food, so as to avoid injuring the 
young adhesion by flatulent distention. Potatoes, peas, and broad-beans 
should be forbidden. Farinaceous puddings and sweets should be greatly 
restricted in quantity. In fact, the child should be dieted much as if he had 
lately passed through an attack of enteric fever. 



CHAPTER XL 

TYPHLITIS AND PERITYPHLITIS. 

The caecum and its appendix are liable to disease on account of the tendency 
to retention of foreign bodies and irritating substances in this part of the 
alimentary canal. In perityphlitis, the inflammatory process begins almost 
invariably in the caecum, and spreads thence to the loose areolar tissue 
around it. In most cases, it is the consequence of ulceration and perfora- 
tion of the wall of the caecum or vermiform appendix. 

Causation, etc. — The form of perityphlitis which is due to ulceration of 
the vermiform process seems to occur more often in early life than in later 
years. Therefore, childhood may be considered to be one of its predispos- 
ing causes. It has been noticed in an infant no more than seven months 
old ; but this is very exceptional. Usually, the child is between four and 
twelve years of age. It is said to be more common in boys than in girls. 

The determining cause of typhlitis is, no doubt, in most cases, constipa- 
tion, with retention in the caecum of hardened faecal matter, constituting 
what Rokitansky named "typhlitis stercoralis." It has, however, been also 
attributed to cold and external injury. I have known it to occur during 
convalescence from typhoid fever. 

Perityphlitis is commonly due to the passage into the appendix of a lit- 
tle concretion, which is retained and sets up inflammation and ulceration. 
Hardened intestinal concretions are often described from their nppearance 
as cherry- or date-stones, but on examination are almost invariably found to 
consist of the earthy phosphates combined with inspissated mucus and or- 
dinary faecal matter.' They may be formed around small foreign bodies, as 
a shot, a pin, or a spicula of bone. In size, they may resemble a pea or a 
date-stone. They have a smooth, shining, waxy-looking surface of a gray- 
ish or brownish colour. Their consistence is hard, and their structure often 
laminated. Sir William Jenner is of opinion that the retention of these cal- 
culi is due in many cases to malposition of the appendix. This process, 
owing to its length and the attachment of its mesentery, may be bent at an 
angle (instead of being directed upwards and inwards), so that hardened 
particles can slip readily into it but are prevented from returning. Accord- 
ing to Dr. Sands, the appendix, before destruction of its coats, contracts ad- 
hesions to the peritoneum lining the iliac fossa ; so that when perforation 
occurs, the faecal matters, instead of entering the serous cavity, gradually 
pass into the loose connective tissue which lies outside the peritoneum. 

In some cases, a typhoid or tubercular ulcer may lead to destruction of 
the wall of the caecum, or the part of the intestine immediately adjoining, 
and be a cause of extravasation. When the escape of faecal matter takes 
place into the loose tissue behind the caecum, it sets up inflammation and 
abscess. An abscess once formed rapidly enlarges, and tends to point some- 
where in the iliac region, or in the groin just above Poupart's ligament. 
The direction in which the pus travels, varies according to the exact seat of 



TYPHLITIS AND PERITYPHLITIS — SYMPTOMS. 679 

the purulent collection. Thus it may pass along the inguinal canal into 
the scrotum, or along the psoas and iliac muscles to the upper part of the 
thigh. Sometimes it clips into the pelvis, and opens into the rectum. In 
other cases, if the ulcerated opening remain patent, the pus may pass 
through it into the caecum ; but often after a time the opening closes up 
so as to shut off all communication with the abscess. 

Often, general peritonitis, more or less severe, accompanies the peri- 
typhlitis, from extension of the inflammation. If, instead of opening into 
the sub-serous tissue, the rupture takes place from the bowel or appendix 
directly into the peritoneal cavity, peritonitis is set up at once. 

Symptoms. — An attack of typhlitis begins suddenly with pain localised 
in the right iliac fossa ; the child vomits, and the bowels are confined. The 
pain is constant, and apparently severe. It is increased by pressure over 
the caecum, by cough, or by efforts to vomit. The matters ejected consist 
of watery and bilious fluids, and the retching may be severe and distressing. 
At the same time, there is fever which varies according to the nervous im- 
pressibility of the child. Usually, the thermometer marks 101° or 102°. 
The expression of the face is anxious and distressed. On palpation of the 
belly, we notice a firm mass in the situation of the ceecum, and gentle per- 
cussion at this spot elicits a dull sound. On account of the tenderness, it is 
difficult to make a satisfactory examination of the iliac region, for the least 
touch causes severe suffering. The child lies on his back, inclining to the 
right side ; he flexes his thigh, and cries bitterly if any attempt is made to. 
straighten the limb. Sometimes a distinct swelling may be noticed at the 
seat of pain. 

These attacks are often spoken of as "colic" or "inflammation of the 
bowels ; " and after recovery, a tendency appears to be left to a recurrence of 
the illness, for it is not uncommon to hear that this is not the first time that 
the child has suffered from similar symptoms. As a rule, if the lesion re- 
main simple, and be not complicated with ulceration of the wall of the bow- 
el, its course is rapid ; and in a few days, under suitable treatment, the pain 
and tenderness are no longer complained of, and the child is convalescent. 
In exceptional cases, the disease lasts into the second week, and the tender- 
ness and swelling only slowly subside. 

Perityphlitis may be preceded by the symptoms described above as being 
characteristic of inflammation of the caecum ; but more often — probably on 
account of the more limited area occupied by the morbid process — the stage 
of ulcerative destruction passes almost unperceived. 

In the first case, the vomiting and constipation cease, and the more acute 
pain gives place to a dull aching, or even altogether subsides. Still, there 
is tenderness, and the swelling does not entirely disappear. The child does 
not seem well. His face retains an expression of distress, and he is dull and 
listless and unwilling to play about. 

If the perforation occur without having been preceded by the symptoms 
of typhlitis, there is often nothing but a sense of dull aching or discomfort 
in the right iliac region, with occasional passing attacks of more acute pain. 
On these occasions, there is vomiting of short duration, and the child looks 
ill, and is feverish. This passes off in the course of a few hours, and the 
child remains as before — not quite well, but suffering from ill-defined symp- 
toms to which little importance is attached. He is peevish and fretful, 
capricious in his appetite, subject to attacks of diarrhoea alternating with 
constipation, and often thirsty at night, with some increase in his tempera- 
ture. 

When perforation occurs, if extravasation take place into the perito- 



680 DISEASE IN CHILDREN". 

neum, all the signs and symptoms of a localised peritonitis are at once 
observed. There is pain, swelling, and tenderness in the right side of the 
belly, with vomiting, constipation, high fever, a furred tongue, and a 
pinched, haggard face. The child lies on his back with his thighs flexed, 
and dreads the least touch. The inflammation may become general, and 
the child quickly die with all the symptoms elsewhere described (see 
Acute Peritonitis). If it remain limited, he may perhaps recover after a 
longer or shorter illness. 

When the perforation takes place posteriorly, so that the extrava- 
sated matters pass backwards into the loose connective tissue behind the 
caecum, the symptoms are less severe. In such cases, the child at first may 
continue to be about. He generally looks ill, has a more or less febrile 
temperature, a capricious appetite, and is listless and languid. He may 
suffer from pain in the iliac region — not very severe, but constant and 
wearing ; or may be attacked by occasional pains of a colicky character, 
which are often excited by movement. At night, the child is restless, 
constantly altering his position, and sometimes crying out. At this period, 
the bowels are usually confined. On examination in the early stage, before 
any pointing of the abscess has occurred, there will often be noticed a ful- 
ness in the right iliac fossa, and this part is tender when pressed upon. 

In most cases, the child, if he continue able to leave his bed, is noticed 
to walk with a limp. Soon, however, he ceases to be able to walk at all, 
and lies in bed on his back with his right thigh partially flexed. If he be 
assisted to stand, he is seen to rest his whole weight on the left limb, and 
to keep his right limb partially bent both at the hip and knee, and rotated 
outwards. With these symptoms, especially if there be any history of a 
blow or fall, disease of the hip-joint may be suspected. This opinion is 
often strengthened by the child's complaining of pain in the knee as well 
as in the groin, and by the suffering caused by any attempt at extension 
of the hip. If the tenderness is great, any rough manipulation of the 
limb, as in rotating the head of the thigh-bone, or communicating any 
concussion to the hip by striking the knee, may be a cause of pain in the 
groin. 

As the disease progresses and suppuration occurs, the pallor and dis- 
tressed expression of the patient are very noticeable. His pyrexia becomes 
more marked, and the evening rise is followed by depression, with sweating 
in the morning. He loses flesh fast, and his tongue becomes dry and 
brown. The constipation now usually gives place to diarrhoea, which may 
be copious ; and the pulse is very rapid and feeble. Great pain is com- 
plained of in the belly which may be distended, or even tympanitic ; and 
the swelling in the right iliac fossa increases in size, but becomes softer. 
Sometimes severe pains are complained of in the right knee and ankle, 
and oedema of the limb may occur from interference with the venous 
circulation. 

If the course of the pus be downwards to the pelvis, so as to show no 
signs of pointing externally, these symptoms, coupled with the resemblance 
of the local condition to hip disease, may suggest a secondary tuberculosis. 
But a careful examination of the belly will usually detect considerable 
fulness and tension in the situation of the cascum. If the pus discharge 
itself into the rectum or bowel, great relief is experienced, and the local 
swelling and tenderness undergo considerable diminution. Often, the 
course of the pus is towards the surface in the neighbourhood of the 
abscess. The skin then becomes darkish red or purple, and swollen. It 
gives a doughy sensation to the touch, and, on pressure, we may notice a 



TYPHLITIS AND PEEITYPHLITIS — SYMPTOMS. 681 

slight emphysematous crepitation. An incision into the softened skin 
allows the escape of brownish, offensive pus and bad-smelling gas. 

These cases generally end fatally. If peritonitis occur, either from 
direct rupture or extension of the inflammation, death usually ensues in 
a day or two. If a faecal fistula remain open, life may be preserved for a 
considerable time — often for years. In most cases, unless the abscess have 
pointed early, the child is so much reduced by pain and hectic fever that 
he does not long survive the opening of the abscess. 

A little girl, aged thirteen years, had an attack of typhoid fever when 
eight years old. After that time she was subject to occasional attacks of 
" colic " and vomiting. Early in December she was ill with what was 
called " inflammation of the bowels with colic," but recovered for the time. 
In the middle of February her bowels became very much confined, and 
after four days' constipation, she had faecal vomiting. An injection was 
given, and a large amount of faecal matter was brought away. 

When admitted into the hospital on February 21st, the child looked ill, 
and was very pale. The belly was distended and tympanitic, with some 
uniform tension of the parietes, but no tenderness or fluctuation. She 
complained of slight colicky pain at times. Her tongue was covered with 
brownish fur, and was inclined to be dry. There was no sickness. The 
bowels had been confined since the injection two days before. The tem- 
perature at 6 p.m. was 93.4°. 

The bowels were unloaded by repeated doses of an aperient saline. 
Afterwards, Small quantities of laudanum were given to relieve the colicky 
pains which still returned at intervals ; and the child was kept quiet in 
bed, with hot applications to her belly. After this, the bowels continued 
to act twice a day, and the stools were normal. 

On March 3d it was noted : " Face pale ; expression distressed ; abdo- 
men not full or tender. The temperature since admission has varied, some- 
times reaching 101°." A week afterwards the child complained of more 
pain in the belly, but this part was not swollen or tender. The bowels were 
a little relaxed. The child began now to lose flesh fast. She continued pale 
and very haggard-looking ; but although she complained of occasional pains 
in the belly, there was no tenderness or swelling, and she never vomited. 
The diarrhoea, however, continued. On March 14th, she began to localise 
the abdominal pain in the right side just over the situation of the quad- 
ratus lumborum. The abdomen was natural in appearance, and not tender. 
The bowels were still loose, and the stools liquid and homogeneous, without 
blood or shreddy matter. 

After a few days, a fluctuating tender swelling appeared just below the 
ribs on the right side, and in front of the mass of the quadratus lumborum. 
This grew larger, and there was much subcutaneous oedema around the swell- 
ing. The child looked ill, and wasted rapidly. Her temperature was be- 
tween 100° and 101°. The swelling was opened by the aspirator, and an 
ounce of brownish, fetid pus was removed. The child, however, sank and 
died two days afterwards. 

On examination of the body, a large abscess was found at the back of 
the caecum, containing much purulent brown matter. The ilium just aoove 
the ilio-csecal valve was distended, and an ulcerous opening was found in 
the wall just above its junction with the caecum. A probe could be passed 
through this opening into the abscess. There was, besides, some slight but 
general peritonitis. The liver was fatty, and both it and the spleen were 
adherent to the diaphragm. Many of the mesenteric glands were enlarged. 

This case of perityphlitis, although really the consequence of ulceration 



682 DISEASE IN CHILDREN. 

of the small bowel, and not of the caecum, illustrates very well the ordinary 
history and symptoms of the disease. The early attacks of colic, accom- 
panied by vomiting, were no doubt owing to the occasional occurrence of 
inflammation in this part of the intestinal tube ; but the ulcerative process 
probably dated only from the illness from which the child had suffered in 
the previous December. This was probably a more severe attack of local- 
ised enteritis. The treatment pursued in this case is not to be recom- 
mended for imitation. Repeated aperients under such circumstances as 
must have existed when the child came under observation, could only be 
injurious. It would have been more judicious to have left the bowels alone, 
or to have administered a sinrple enema. 

Cases of ulcerative perforation of the vermiform appendix require spe- 
cial mention. This, accident is, as has been said, more common in early life 
than after adult age - has been reached. Often, the initial stage of the dis- 
ease has excited no notice, and the first symptoms that arise are due to the 
extravasation of the contents of the bowel into the peritoneum. In most 
cases, all the symptoms of acute peritonitis ensue, and the child rapidly 
dies. The consequences of the extravasation are not, however, always so 
easy of recognition. In the chapter on Acute Peritonitis, mention is made 
of the occasional latency of the abdominal symptoms in cases where the 
peritoneum is inflamed. This is sometimes the case when the inflamma- 
tion is set up by matters extravasated from the bowel ; and we may find, as 
a result of perforation of the appendix, merely pain, vomiting, constipation, 
and some fever — symptoms which are not characteristic of peritonitis, but 
tend rather to suggest obstruction of the bowel. In fact, not once, but 
many times, such cases have been treated for obstruction, even to the extent 
of actual surgical interference. The obstinacy of the constipation, the per- 
sistency of the vomiting, and the colicky character of the pain, make the 
resemblance curiously close. Often, indeed, very careful examination is re- 
quired to detect the real nature of the attack. It is of extreme importance 
to remember that traumatic peritonitis in the child may be ushered in by 
such symptoms ; and in every case of supposed obstruction of the intestine, 
we should search carefully for some other cause for the illness. 

Sometimes, on inquiry we find that on previous occasions the child had 
complained of slight abdominal pain, lasting for twenty-four hours, or 
perhaps two days, with tenderness in the csecal region and a siugle effort 
of vomiting. These passing attacks may be accompanied by flatulence, 
constipation, or diarrhoea, and a feeling of distention of the belly. They 
are due, no doubt, as Dr. With has pointed out, to ulceration of the vermi- 
form appendix, with commencing adhesive peritonitis. After perforation 
has occurred, the local symptoms may remain limited to the iliac region, 
or may spread to the whole abdomen. In the first case, if the disease be 
recognised and properly treated, the child may perhaps recover ; in the 
second case, he usually dies. Ileus may occur before death. 

Diagnosis. — Typhlitis is accompanied by such characteristic symptoms 
that its detection is not a matter of difficulty. A sudden attack of abdom- 
inal pain and tenderness referred to the region of the right iliac fossa, 
accompanied by vomiting, constipation, a pinched, anxious expression, and 
some fever, at once draws attention to the belly. On examination, the 
presence of an intensely tender swelling in the situation of the caecum, 
together with the drawing up of the thigh on the affected side, sufficiently 
indicates the nature of the illness. If the occurrence of vomiting and 
obstinate constipation, combined with a localised swelling and severe 
abdominal pain, should suggest intussusception, we may remember that 



TYPHLITIS AIYD PEKITYPHLITIS— DIAGNOSIS. 683 

in the latter disease tenderness and signs of local peritonitis are not early 
symptoms ; that the tumour, if felt, is commonly detected on the left side 
of the abdomen ; and that violent straining, with the passage of bloody 
mucus, is a very constant and prominent symptom. 

If, after the signs of general constitutional disturbance have subsided, 
the local symptoms do not disappear, but more or less tenderness, pain, 
and swelling persist ; or if, after disappearing, the acute symptoms return 
after only a short interval, and this recurrence happens several times, in 
either case we have reason to fear that the inflammatory process is going 
on to ulceration. The occurrence of peritonitis at this time will coirhrin 
our apprehensions, and indicate extravasation into the cavity, of the peri- 
toneum. If, however, the wall be perforated posteriorly, and an abscess 
form behind the caecum, the symptoms are much less striking. 

If the patient be not confined to his bed, he often complains of tender- 
ness in the right groin, and halts upon the right leg. The case is then 
distinguished from hip disease by noticing that although the child keeps 
the thigh partially flexed, and is greatly distressed when any attempt is 
made at passive extension, the head of the femur may be rotated readily 
and without pain, if it be done with care ; and that pressure upon the hip- 
joint on or behind the trochanter, causes no discomfort if the patient's 
whole body be not jolted at the same time. Often, the child, while lying 
on his back, will readily flex the thigh, and perform the movements of 
abduction and adduction. It is only extension which appears to be im- 
possible, and any attempt to straighten the limb causes severe pain. It 
will be remarked, too, that while the history indicates shortness and 
acuteness in the illness, the symptoms, if they could be referred to the 
hip-joint, would suggest disease of considerable duration. Lastly, wasting 
of the muscles of the thigh, which occurs early in acute hip disease, is 
absent ; the gluteal muscles on the affected side are not flattened, nor is 
the fold of the buttock lowered ; the fold in the groin below Poupart's 
ligament is not obliterated ; and distinct swelling and tenderness can be 
detected in the right iliac fossa. 

Directly signs of pointing are noticed, any remaining obscurity in the 
case must disappear. 

Ulceration and perforation of the vermiform process are very difficult 
to recognise with certainty, as the first symptoms noticed are often those 
due to the extravasation into the peritoneal cavity. Severe peritonitis 
coming on suddenly, especially if the pain and tenderness can be ascer- 
tained to have started from the right iliac region, is very suspicious of 
this accident. Essential peritonitis comes on gradually, and the ordinary 
forms of peritonitis from perforation are preceded by some severe acute 
illness. It is important to bear in mind that the phenomena resulting 
from perforation of the csecal appendix may be far from characteristic of 
inflammation of the peritoneum ; and in every ease where symptoms arise 
pointing to sudden obstruction of the bowels (pain, vomiting, and consti- 
p ition). accompanied by fever, we should carefully exclude this and other 
possible causes of such symptoms before committing ourselves to the 
diagnosis of intestinal occlusion. 

Prognosis. — Simple typhlitis almost always ends favourably ; but if 
perforation occur, and extravasation take place into the peritoneum, re- 
covery rarely follows. If a retro-peritoneal abscess result from the per- 
foration, the prognosis is less unfavourable ; but here, too, the patient 
often dies from exhaustion, or from extension of the inflammation to the 
serous membrane. The most favourable course is that in which the abscess 



684 DISEASE IN CHILDEEN. 

discharges itself again into the bowel. Of the cases where it opens ex- 
ternally, a large proportion die. Perforation of the csecal appendix is 
usually fatal. 

Treatment. — In every case of typhlitis our chief care should be to quiet 
peristaltic action, and prevent any movement of the bowels, by the free use 
of opium. Whether the inflammation has had its origin in a collection of fae- 
cal matter in the caecum, or has been induced by other causes, the same 
necessity exists for keeping the bowels at rest until the inflammation has 
subsided. Therefore an aperient in any shape is not to be thought of for 
a moment. Even enemata would be injurious while the acute symptoms 
continue. 

The child should lie in bed, with a small pillow under his right knee ; 
and hot linseed-meal poultices should be applied to the right side of the 
belly, and be frequently changed. Opium should be given by the mouth. 
A child of eight years of age will take three drops of laudanum every four 
hours. If this be vomited, morphia (one-sixteenth to one-twelfth of a grain) 
can be injected subcutaneously in its stead. The vomiting is, however, 
usually checked by the opiate, and the second attempt to administer it in 
a draught is often successful. A good combination in these cases is that 
of the tinctures of opium and belladonna. The latter drug is not only of 
great service in most forms of arrested function of the bowels, but also 
by its antagonistic action tends to modify the narcotic influence of the laud- 
anum without interfering with its power as a sedative. If this combination 
be used, five drops of tincture of opium may be given with twenty of the 
belladonna tincture three times a day to a child eight years of age. 

If the child be very strong, and the tenderness severe, three or four 
leeches should be applied to the painful spot. 

The diet must consist of milk and broth, given in small quantities at a 
time. The milk should be diluted with an equal quantity of barley-water, 
to separate the particles of curd and prevent their coagulating in a lump. 
It should be also alkalinised by fifteen or twenty drops of the saccharated 
solution of lime to the teacupful. 

When the acute symptoms subside the bowels will generally act spon- 
taneously. If they do not, an injection can be administered. Purgatives 
of any kind should be avoided for some time after convalescence is estab- 
lished. We can never be sure that some slight ulcerative process is not 
going on, and the only hope of the child in such a case would be the 
establishment of sufficient adhesions to prevent rupture and extravasation. 
Such adhesions, if formed, an aperient would probably destroy. 

In cases where we have reason to suspect the presence of a retro-csecal 
abscess, the same reason for the avoidance of purgatives exists. The child 
should be kept in bed, and hot applications should be applied to the pain- 
ful part. He should be fed with nourishing food in small quantities at a 
time ; and a suitable proportion of stimulant should enter into his diet. 
Minced mutton and chicken, -strong beef-essence, yolk of egg, milk and 
toast should form the staple of his food. If the bowels are obstinately con- 
fined, or fsecal vomiting occur, an enema may be administered, but purga- 
tives should be avoided. For medicine, quinine and a mineral acid, with 
small doses of strychnia may be given, and as the child grows weaker, am- 
monia and bark. Directly signs of pointing are noticed the pus should be 
let out at once. 

If peritonitis occur, the treatment must be conducted as directed in the 
chapter treating of that subject. 



CHAPTER XII. 

ACUTE PERITONITIS. 

Acute peritonitis may occur in childhood at any age. It may be pres- 
ent in the foetus, usually as a consequence of syphilis, and is then a frequent 
cause of miscarriage. It may arise in the new-born infant as a result of 
pysemic infection, and is invariably fatal. It may occur at a later period of 
infancy or in childhood, either as a primary disease, or as a secondary mal- 
ady complicating the course of some other illness. The infective form of 
peritonitis which occurs in the new-born baby, and is accompanied by jaun- 
dice, is described elsewhere (see Jaundice). The present chapter deals only 
with the disease as it is seen in later infancy and childhood. 

Causation. — As in the adult, inflammation of the peritoneum in children 
is often induced by traumatic causes. A bloAv or other injury to the abdo- 
men will occasionally excite it, and it may arise as a consequence of punc- 
ture of a hydatid cyst. The commonest of these causes is the extravasation 
of fluids from the bowel into the peritoneal cavity, owing to perforation of 
the intestine. In typhoid fever, and in ulceration of the vermiform appen- 
dix or of the caecum, this accident may happen, and a rapidly fatal issue to 
the illness usually follows. Dr. Eobert Lee has referred to two cases in 
children, aged respectively eight and nine years, in whom perforation of the 
stomach induced the peritonitis. Sometimes a local inflammation of the 
peritoneum may become diffused, as when a typhlitis or perityphlitis, or 
an invaginated portion of the intestine sets up general peritoneal inflam- 
mation. Mr. Curling has recorded the case of a little boy, aged two years, 
in whom the bruising of an undescended testicle produced this result. 
Again, inflammation may extend from the chest to the abdomen. I can 
now recall several cases in which a pleurisy has been followed by general 
inflammation of the peritoneum. I have known this to happen in the first 
week of the illness, before the fluid had had time to become purulent ; but 
in most cases it occurs later, as a result of the passage of purulent infective 
matter from the pleural cavity along the lymphatics of the diaphragm to 
the peritoneum. In order that this extension should occur, there must, no 
doubt, be present some special conditions conferring peculiar infective 
properties upon the purulent contents of the thorax. Dr. Burney Yeo has 
described the case of a schoolboy, between eleven and twelve years of age, 
who was attacked in the course of whooping-cough by pleuro-pneumonia 
of the left side of the chest. Nineteen days afterwards this was followed 
by general peritonitis, and the patient very rapidly succumbed. The same 
unfortunate accident happened to a little boy, eighteen months old, under 
my care in the East London Children's Hospital. The child had an attack 
of pleurisy. As the fluid did not become absorbed his chest was punctured 
and a quantity of purulent matter was evacuated. The operation had to 
be repeated several times, and at last, as the purulent fluid still continued 
to reaccumulate, a permanent opening was established in the chest-wall. 



686 DISEASE IN CHILDPwEjST. 

The boy seemed to be going on fairly well when extension of the inflam- 
mation suddenly took place to the peritoneum and he soon died. 

Peritonitis is sometimes a complication of the blood diseases. It is 
said occasionally to occur in scarlatina, and erysipelas may induce it. 
Abercrombie has referred to an epidemic of the latter distemper which 
occurred amongst the children in the Merchants' Hospital in Edinburgh 
in the year 1824. The disease was of a mild type, but two of the children 
rapidly died, and on examination pus was discovered in the abdominal 
cavity. Peritoneal inflammation is also common as a consequence of 
abdominal tuberculosis, but the subject of tubercular peritonitis will be 
considered separately. 

Besides occurring as a result of the above causes, peritonitis may arise 
as a primary disease in a child in whom no deviation from health has 
been noticed. It is sometimes seen in school-children of either sex, and 
has been attributed by Gauderon to chilling of the surface after violent 
exercise, and by Legrand to lying prone upon the damp earth. 

Morbid Anatomy. — The pathological characters of peritonitis are the 
same in the child as in the adult. The vessels are injected, and the 
normal polish of the serous surfaces is lost, owing to inflammatory exuda- 
tion. There is infiltration and thickening of the sub-serous tissue, with 
proliferation of cells in the epithelial covering of the membrane. The 
exudation poured out from the distended capillaries coagulates on the 
surface and forms a false membrane, which is at first thin and grayish in 
colour, afterwards thicker and yellow. It causes adhesion between neigh- 
bouring organs, and glues the coils of intestine to one another. There is 
besides effusion into the abdominal cavity. Its quantity varies. Some- 
times it is copious. The fluid is usually opalescent, from proliferated 
epithelial cells, or may be distinctly purulent. 

The longer the disease continues, the tougher and thicker the exuda- 
tion becomes, so that it may form bands which pass from one organ to 
another, and in long-standing cases may constrict portions of the bowel 
and cause serious consequences. If the patient survive, the fluid becomes 
absorbed, and the exudation gets tougher and forms firm adhesions be- 
tween neighbouring parts, as well as opaque fibrous patches upon the 
surface of organs, more or less thick and hard. When the peritonitis is at 
first partial, as may happen when the inflammation is due to perforation 
of the bowel, the exudations and consequent adhesions may confine the 
extravasated matters within certain limits, and thus localise the inflamma- 
tion. 

Pent-up collections of matter may also arise in the following manner : 
On account of gravitation the purulent fluid is apt to collect in certain 
spots, especially above and behind the liver. If the child do not die, the 
fluid, thus accumulated, may become shut off by adhesions so as to pro- 
duce a local abscess. Abscesses arising in this way are usually seated 
near the diaphragm, often between that muscle and the liver or spleen. 
Such a collection of matter may eventually open into the chest and set up 
pneumothorax. 

Symptoms. — In the child peritonitis may give rise to violent and acute 
symptoms, as it does in the adult. As a rule, it is the primary form — 
essential peritonitis, as it has been called — which is accompanied by these 
signs of serious disease. Also, when the inflammation follows upon a blow 
or other external injury in a child previously in good health, the symptoms 
are usually striking and severe. In the secondary form, when the child is 
already reduced by illness, the symptoms, although often sufficiently pro- 



ACUTE PERITONITIS — SYMPTOMS. 687 

nounced, may yet be to a certain extent masked by the state of profound 
collapse into which the patient is thrown. In other cases the disease may 
be more or less latent, and indeed is sometimes not discovered until the 
body is subjected to examination in the dead-house. 

In the severe primary form the child complains, often quite suddenly, 
of pain in some part of his belly — in either flank, above the pubes, or about 
the navel. At first comparatively slight, the pain soon gets more severe 
and general, and at the same time the belly becomes tender. Vomiting is 
almost always an early symptom. The child first ejects partially digested 
food, and then glairy and bilious matters. If the efforts., to vomit are vio- 
lent, they occasion great distress, on account of the pain and tenderness of 
the belly ; and after each effort the child lies back with haggard,- pale face, 
beads of sweat standing upon his brow. Fever is present.from the begin- 
ning, and may be preceded by a sense of chilliness, or even distinct rigors. 
The degree to which the temperature rises varies, as it does in inflamma- 
tion of the other serous membranes in the child. Sometimes it may reach 
104°, or even higher, but at other times it remains little over 100°. The 
average degree of pyrexia is perhaps between 101° and 102°. At night the 
child is restless and sleeps little, often waking up and crying with pain in 
his belly. Sometimes he is disturbed by delirious fancies and talks wildly. 

Almost from the first the child is unwilling to move, and he soon takes 
to his bed. There he lies upon his back, or inclining to one side, with legs 
and thighs flexed. His face is pale and distressed, his nose looks sharp, 
and the nostrils are thin and expanded. The slightest touch upon the belly 
is painful, and he seems to dread the least movement. If the coat of 
the bladder is involved, there is retention of urine. If the peritoneal 
coat of the bowel is inflamed, attacks of the most violent colic may come on 
at intervals, and throw the child into an agony of pain. On examination 
of the belly, this is seen to be distended with gas ; it is motionless in res- 
piration ; there is some tension of the parietes, and the tenderness is exces- 
sive. Gentle percussion elicits a tympanitic sound over the anterior re- 
gions ; but in the depending parts, where the fluid collects, the note is dull. 
Sometimes the fluid is sufficient in quantity, and sufficiently free, to give a 
distinct sense of fluctuation ; but the absence of free fluctuation is no sign 
of the absence of fluid. There is often effusion between the coils of intes- 
tine and in the meshes of the exuded lymph ; but this transmits the wave 
of fluid very imperfectly from one side of the belly to the other. As a 
general rule, perhaps, fluctuation is imperfect or absent. In these cases 
Duparcque has suggested that the child should be placed on his side for a 
few minutes. The whole quantity of fluid will then gravitate to the flank 
on the depending side. If the child be then quickly turned upon his back, 
dulness and fluctuation will be found at first at the site of the accumulated 
fluid, but owing to the second change of position will quickly disappear. 

If the distention of the abdomen become great, it may cause serious 
distress by compressing the lungs and displacing the heart. In such cases 
there is dyspnoea, with some lividity of the face, and hurry of breathing. 
The tongue is furred on the dorsum, red at the tip and edges. The pulse 
is small, hard and frequent. The urine is high coloured, but not espe- 
cially acid, and its passage causes no pain. The bowels are confined or re- 
laxed. Constipation is the rule in adults, but in children it is common to 
find looseness of the bowels with watery and offensive stools. Still, even in 
the child, if the muscular coat of the bowel be involved, and there be no 
sub-mucous oedema to cause effusion into the intestinal tube, the bowels 
may be obstinately confined. 



688 DISEASE IN CHILDREN. 

As the illness progresses the vomiting usually ceases, but the other 
symptoms become more and more severe. The tympanitis increases ; the 
tongue becomes dry and brown ; the eyes are sunken ; the face is haggard 
and pale, often cyanotic. The child lies with his eyes half closed in a dreamy 
state. His pulse is excessively small and rapid ; and death usually occurs 
by the end of the week. 

In exceptional cases the disease ends in recovery, the fluid being ab- 
sorbed or discharged through the navel or abdominal wall. I have met 
with one case in which purulent matter escaped in large quantity through 
the umbilicus, and the child recovered. If the pus be evacuated by this 
channel, the relief experienced by the patient is usually extreme. The vol- 
ume of the belly is diminished ; vomiting, if it had persisted, ceases ; the 
tongue begins to clean, and some signs of returning appetite are manifested. 
M. Gauderon has referred to ten such cases, in eight of which recovery took 
place. The fistula left after the discharge of the purulent matter closes in 
about a month, sometimes at an earlier date. The disease is said some- 
times to pass into a chronic state. Such a termination would excite sus- 
picions of a tubercular origin for the peritonitis. There are few recorded 
cases of chronic peritonitis in the child, where an opportunity of examining 
the body was afforded, which do not make mention of tubercle in the ab- 
dominal cavity or in the lungs. 

When the peritonitis is the result of perforation of the bowel, the oc- 
currence of this serious accident is indicated by sudden severe pain in the 
belly, which becomes distended with gas and excessively tender. At the 
same time the child is reduced by the shock to a state of collapse. His 
face is haggard and ghastly looking ; his eyes are deeply sunken ; his pulse 
becomes very quick and small ; his breathing is thoracic ; his hands and 
feet are cold, but the temperature of the body, if taken in the rectum, is 
found to be 103°, 104°, or even higher. Sometimes he vomits, and the 
secretion of urine is suppressed. On examination of the belly it is found 
that the liver dulness has disappeared. Niemeyer gives this as a certain 
sign that peritonitis resulting from perforation of the bowel has taken place. 

The above is the typical form ; but often the symptoms are much less 
characteristic. Pain and tenderness may be little complained of, and, as 
Andral has pointed out, sudden increase of the prostration and the ghastly 
look of the face may be the only symptoms drawing attention to this new 
complication. Even when the pain has been ^e _ ;ere, it often ceases com- 
pletely for some hours before death. In most cases the child survives 
perforation but a very few days. Sometimes, if adhesion have previously 
taken place in the neighbourhood of the ulcer, so as to confine the extra- 
vasated matters to the immediate vicinity of the rupture, the peritonitis 
may be localised. An abscess then forms, which after a time makes its 
way to some point of the surface, and discharges its contents externally. 
Under these more favourable conditions the child may recover, but it is 
needless to say that such cases are exceptional. 

Sometimes peritonitis in the child is entirely latent, and is only dis- 
covered on post-mortem examination of the body. In such cases the 
belly may be swollen, and the child may look ill and colourless ; but pain 
may not be complained of ; there may be no tenderness of the abdomen, 
no tension of the parietes, no fluctuation, or other sign to indicate the 
presence of this serious lesion. I have only observed this latent form in 
cases of secondary peritonitis. In the little boy, whose case has been be- 
fore referred to, where peritonitis resulted from extension of the purulent 
inflammation to the belly from the chest, the abdomen was swollen, and a 






ACUTE PEEITONITIS — SYMPTOMS — DIAGNOSIS. 

watery diarrhoea began which resisted all treatment ; but there appeared 
to be no pain or tenderness ; the parietes were soft and flaccid ; no fluc- 
tuation could be detected ; and although on account of its fulness the ab- 
domen was repeatedly examined, nothing was discovered to lead to the 
suspicion of the existence of peritonitis. On examination of the body 
some purulent fluid was discovered in the peritoneal cavity, and the bowels 
were more or less adherent from exuded lymph. It is important to be 
aware of the occasional latency of the inflammation, so that we may not 
exclude peritonitis, because the symptoms and signs are ill marked and 
little characteristic of the lesion. If in such a case the delirium, restless- 
ness, and tendency to stupor are unusually prominent, the most experienced 
physician may misapprehend the nature of the illness and be disposed to 
suspect the onset of a meningitis. Dnparcque relates a case in which this 
mistake was actually made, and the error was only discovered on examina- 
tion of the body. 

Diagnosis. — When the symptoms are well marked the diagnosis of the 
disease is easy. Swelling of the belly, which takes no part in the respiratory 
movement and is intensely painful and tender ; vomiting ; a pale haggard 
face, and a quick wiry pulse — these, together with the position of the child 
in his bed, with the thighs flexed, and his dread of movement or even of a 
touch, form a very characteristic group of symptoms. 

When the inflammation is a consequence of perforation of the bowel, 
the complication is sufficiently clear. Even if the pain and tenderness are 
inconsiderable, the sudden occurrence of collapse with tympanitis suffi- 
ciently indicates what has occurred. 

From tuberculous peritonitis the acute simple form may be readily 
distinguished by the more violent character of the symptoms and the 
more rapid course of the disease. In the tuberculous variety vomiting is 
rare, and the illness runs, as a rule, a very slow and chronic course. 

In colic there is often constipation and vomiting, with severe par- 
oxysmal pain in the belly ; but between the attacks of pain there is no 
tenderness ; the pulse is less rapid, small, and wiry, and there is none of 
the fear of movement which is so characteristic of peritonitis. 

Rheumatism of the abdominal wall may be mistaken for inflammation 
of the peritoneum. The distinctive characters are given elsewhere (see 
page 159). 

It is important to remember the occasional latency of the symptoms in 
peritonitis. Tension of the abdominal parietes on palpation, especially 
if partial, in a child above the age of infancy, must not be disregarded. 
It may, of course, be voluntary, and the belly be quite healthy ; but if the 
abdomen is full, and the child looks ill, with a haggard, pinched face, we 
should consider the possibility of peritonitis, and make a very careful ex- 
amination. In cases of chronic empyema we should be always on the 
watch for the occurrence of peritonitis. If the child, after a period of im- 
provement, cease all at once to gain ground and begin to look pale and 
distressed, with an elevated temperature, a more or less distended belly, 
and a rapid, wiry pulse, we are justified in suspecting peritonitis although 
there be no tension, tenderness, or other sign connected with the abdo- 
men to give support to this opinion. 

It is well in all cases where a feverish child looks ill and has a dis- 
tended belly, to make trial of Duparcque's plan of placing the patient for 
a minute or two on his side, so as to allow all the peritoneal fluid to collect 
in the depending flank. Turning him, then, quickly upon his back, evidences 
of fluid, if peritonitis be present, will be found at the site of accumulation. 
44 



690 DISEASE IN CHILDREN. 

Had this been done in the case of the little boy already twice referred to, 
the cause of the distention of the abdomen would not have escaped re^ 
cognition. 

When the inflammation affects exclusively the visceral peritoneum, the 
muscular poat of the bowel is usually implicated. There is then often 
obstinate constipation from paralysis of the affected portion of the intes- 
tine ; there may be vomiting ; and excessive tenderness of the belly is 
combined with paroxysms of colicky pain of agonizing severity. Such cases 
may simulate very closely obstruction of the bowels, and may be mistaken 
for intussusception. Some time ago I saw, with Mr. Izod, of Esher, a young 
lady, aged ten years, who had got up in her usual health on the morning 
of the previous Sunday. In the afternoon of that day, after running about 
in the garden (the day was very damp) she complained suddenly of pain 
in the belly. That night she slept fairly well, but complained of pain 
again on the next (Monday) morning. A pill was given to her, followed 
by a saline. 

This acted on the bowels, but the pain was not relieved. She slept 
badly that night. On the Tuesday morning she was seen by Mr. Izod, 
who found a temperature of 102°. There was some tenderness of the 
belly, with frequent paroxysms of colicky pain. She had had no vomiting. 
Opium was given, but the pains continued, becoming more and more fre- 
quent and more and more severe. The bowels were confined all the week 
except on the Thursday, when they acted spontaneously twice, the stools 
being copious and lumpy, light coloured and rather offensive. I saw the 
child, with Mr. Izod, on the following Sunday — the eighth day. She was 
lying in bed hollow-eyed and livid. Every ten minutes a paroxysm of 
pain came on, during which she raised herself up in an agony and tried 
to get on to the floor. The belly was swollen and excessively tender, the 
slightest touch appearing to induce a fresh access of pain. The child had 
been kept for some time under the influence of chloroform, but when the 
anaesthetic was remitted the pain instantly returned. Hypodermic in- 
jections of morphia and atropine were given repeatedly ; but large quan- 
tities of these narcotics appeared to dull the pain but slightly. The child 
died on the following day. 

On examination of the body the small intestine was found healthy, ex- 
cept for a reddened and ulcerated patch in the middle of the jejunum. 
The large bowel was distended with liquid fseces. Its parietal coat was 
very red and inflamed, but there was no injection of its mucous lining. 
The parietal peritoneum was not inflamed. Its cavity contained much 
dirty serum, but no lymph. 

If the inflammation, instead of being confined to the visceral perito- 
neum, spreads through the muscular coat to the mucous membrane (phleg- 
monous enteritis) there is, in addition to the above symptoms, a profuse wa- 
tery diarrhoea. The diagnosis is then easy. If the mucous membrane is not 
implicated, there is constipation which may be obstinate. In such a case 
intussusception may be excluded by noticing the early occurrence of ten- 
derness, of abnormal tension of the abdominal wall, and in most cases of 
fever. Moreover, there is no tenesmus ; and the passage of blood and 
bloody mucus from the bowel, which is such a characteristic feature of 
intussusception, is absent. If, as in the case just narrated, an action of 
the bowels, spontaneous or otherwise, occurs some days after the be- 
ginning of the illness, there is evidently no complete obstruction of the 
intestinal channel ; but unless the invaginated portion of gut be tightly 
constricted, secondary peritonitis is very unlikely to arise. 



ACUTE PERITONITIS — PROGNOSIS — TREATMENT. 691 

Prognosis. — The disease is fatal in the large majority of cases. In 
primary peritonitis from cold the chances are perhaps a trifle less unfa- 
vourable than in the other varieties. Kestlessness and inability to sleep 
are bad signs. In partial peritonitis, if the inflammation remain localised, 
the child will sometimes recover. 

Treatment. — Directly the existence of peritonitis is ascertained no time 
should be lost in resorting to energetic measures for its removal. The 
most perfect quiet in bed should be enforced, and the presence of too 
many attendants should be strictly forbidden. One good nurse can do all 
that is required. Turpentine stupes should be applied to the belly, and 
opium should be given by the mouth or by hypodermic injection. For a 
child ten years of age six or eight drops of laudanum may be given in a 
teaspoonful of water every four hours, or one-twelfth of a grain of morphia 
may be injected under the skin, and the operation can be repeated* as re- 
quired. It is best to produce drowsiness, with some contraction of the 
pupil. Children vary greatly in their susceptibility to this form of nar- 
cotic ; but inflammation of the peritoneum, if the pain is great, may require 
larger quantities of the drug than one would be disposed to anticipate to 
produce a sufficiently sedative effect upon the patient. Thus, I have known 
a little infant of four months old, who was suffering from agonising colic, 
owing to inflammation of the peritoneal coat, of the bowels, take three 
minims and a quarter of laudanum in the space of two hours, with but 
little remission of his suffering. The same infant some hours afterwards 
had a hypodermic injection of one-twelfth of a grain of morphia ; and this 
powerf ill dose, although it contracted the pupils to the size of a pin's point, 
did not completely suppress all signs of pain. Energetic counter-irri- 
tation is of great value in these cases, and when the turpentine can no 
longer be endured upon the abdomen, it may be applied to the front of the 
chest or to the back. Cold applications are well borne in many cases, and 
seem sometimes to comfort more than hot flannels. Cold is employed by 
means of cloths wrung out of ice-cold water and frequently changed. 

All purgatives are to be avoided. If it be considered necessary to re- 
lieve the bowels, this can be done by enema. If the peritoneal coat of the 
intestine is involved, constipation is often absolute ; but it is best to make 
no attempt to excite a movement. Our object is to quiet peristaltic action 
and insure rest. Probably the chief value of opium consists in its in- 
fluence in this direction. Any attempt, therefore, to oppose its action 
will be hurtful. If in these cases the paroxysms of pain are frequent and 
agonising, it is advisable in a robust subject to apply leeches freely to the 
abdomen. I believe this form of disease to be one in which the abstrac- 
tion of blood is a distinctly valuable therapeutic means ; and should not 
hesitate to employ ten or twelve leeches, or even more, if the attacks of 
colicky pain resisted the action of morphia. Even when the inflammation 
is limited to the parietal peritoneum, leeches may be employed in the case 
of a sturdy child, when the disease is primary, especially if the pain and 
tenderness can be referred to any particular spot. In many severe cases 
of peritoneal enteritis, where the pain is excessive, and morphia, even fol- 
lowing the application of leeches, proves impotent to control the paroxysms 
of suffering, it is advisable to keep the child under the influence of chloro- 
form. 

If thirst be much complained of, it is best allayed by sucking ice ; and 
the same measure is also useful in checking the tendency to vomit. The food 
should be concentrated. Strong beef-essence, milk in small quantities at 
a time, and yolk of egg can be given ; and as the patient becomes weaker, 



692 DISEASE IN CHILDREN. 

a teaspoonful of sound brandy in milk or water should be administered 
every few hours. 

Tympanitis is a symptom which it is difficult to treat successfully. I 
have never seen benefit result from enemata of assafcetida or the passage 
of a long tube into the bowel. It is best relieved by free stimulation, and 
the external application of turpentine. If the child survive, and the 
abdominal distention continue after the inflammation has begun to sub- 
side, as a consequence of loss of tone in the bowel, gentle frictions to the 
belly, compression with a flannel bandage, and quinine and strychnia by 
the mouth are of service. 

"When peritonitis is the result of perforation of the bowel, warmth to 
the abdomen and the feet, the free use of opium, concentrated food, and 
energetic stimulation offer the best chances of success. 

In«every case where collections of matter can be discovered under the 
skin, either at the umbilicus or elsewhere, no time should be lost in aiding 
the escape of the pus by the puncture of a lancet. 



CHAPTER XIII. 

TUBERCULAR PERITONITIS. 

The inflammation of the peritoneum which results from abdominal tuber- 
culosis usually runs a subacute or chronic course. The disease is rarely 
acute ; but it is important to be aware that an acute form is occasionally 
met with, and is very difficult to detect. Tubercular peritonitis may be 
the only indication of the tubercular disease to be discovered in the body, 
or may be accompanied by signs of distress from other parts of the system. 
It is rarely seen in young* children, perhaps never in infants, and does not 
begin to be a common affection before the seventh or eighth year of life. 
After that age, however, it is frequently met with. The earliest age at 
which the disease has come under my notice has been three years. 

Morbid Anatomy. — On opening the abdomen in a case of tubercular 
peritonitis we find the bowels covered more or less completely with yellow- 
ish, greenish, or gray coloured lymph. The consistence of this varies. 
It may be loose and soft in texture, or tough. Usually it is mixed up 
with thick cheesy matter. The lymph often lines the parietal peritoneum, 
and penetrates between the coils of intestine, which it glues firmly together. 
Sometimes the whole bowel is so matted together into a confused mass 
that it is quite impossible to follow out the course of the canal. More or 
less greenish or yellow purulent matter is held in the meshes of the exuded 
lymph, and more is seen to have gravitated to the deeper parts of the 
abdominal cavity. On clearing away the lymph from the surface of the 
peritoneum and contained organs, we find gray and yellow granulations 
studding the surface more or less thickly. With these are larger masses 
and even broad plates of cheesy matter, probably also tubercular in their 
nature. These are yellow or fawn coloured, and may be dotted with 
black points of pigment. Similar cheesy masses may be discovered lying 
in the adhesions formed by one organ with another — between the liver or 
the stomach and the diaphragm, and between the coils of intestine. The 
more chronic the case the larger and thicker are the caseous masses. 
When the case is acute, these are usually absent ; but the serous surface 
is covered with lymph in the substance of which are scattered gray and 
yellow granulations varying in size from a pin's head to a pea. 

The larger tubercular cheesy masses may cause the intestinal wall to 
give way, perforated from without. Extravasation of the contents of the 
intestine rarely takes place into the peritoneal cavity, owing to the existence 
of the firm adhesions ; but in this way a new and unnatural communication 
may be formed either between two different parts of the intestinal tube, as 
was noticed by Messrs. Killiet and Barthez, or between the bowel and the 
umbilicus, as happened in a case recorded by Henoch. 

In the most chronic cases the adhesions may be very tough and fibrous, 
and even the lymph on the peritoneal surface may resemble connective 
tissue. The omentum, itself unusually firm in its texture, may be ad- 



094 DISEASE IX CHILDREN. 

herent to the abdominal wall ; and the mesentery may be tough and con- 
tracted. 

Tubercular peritonitis is not always general. Sometimes it is partial, 
and is then usually confined to the upper parts of the abdominal cavity — 
the neighbourhood of the diaphragm, the liver, and the spleen. The liver 
itself is often enlarged from amyloid or fatty change, and has been found 
by some observers to be cirrhotic. The bowels are often the seat of tuber- 
cular ulceration, and the mesenteric glands are enlarged and cheesy. 

Besides the peritoneum, tubercle is often found in other organs. In 
the more chronic cases it may be limited to the abdomen ; but in the 
acute form the abdominal disease is almost invariably a part of a general 
development of tubercle over the body. 

-• Symptoms.— Tubercular peritonitis always begins insidiously, and its 
symptoms may be far from being well marked. In some cases attention 
is diverted from the belly by the more striking phenomena arising from 
tubercle, and the consequences it involves, in other organs ; but even if 
the tubercular granulations are limited to the abdomen, the early symp- 
toms are often curiously insignificant when we consider the serious nature 
of the disease. In these cases of local tuberculosis the general nutrition 
may be good at first, and the appearance of the patient fairly robust ; but 
as the illness progresses the child rapidly loses flesh, colour, and strength, 
and before death occurs may reach an extreme degree of emaciation. 

In an ordinary case, the first sign noticed by the mother is that the 
child's belly looks large, and the next, that it is a little tender. The child 
is unusually listless and dull. He looks ill. He avoids exercises which 
cause a jolt or jar to his body, and shows a caution in all his movements 
which soon attracts attention. 

A boy between ten and eleven years old was brought to me at the hos- 
pital. The lad had always been healthy and active, although there was a 
tendency to consumption in his family. For some weeks it had been 
noticed that he looked pale, often complained of nausea after food, was 
languid, lay about instead of playing, and cried if he was scolded. Then 
he began to suffer from pains in his abdomen, and excused himself on this 
account from running errands as he had been accustomed to do. Pressure 
on the belly, as in leaning against a chair or table, had not been noticed to 
be painful ; but the boy said that if he leaned forward his "food " rose at 
once. After some days the abdomen began to be tender and painful. The 
child complained of feeling cold, and slept badly at night. He was thirsty, 
but cared little for food. The bowels were relaxed. 

The above is a very good illustration of the mildness of the early 
symptoms, and the stealthy way in which the disease creeps on. The ab- 
dominal pains appear to be at first intermittent and of a griping character. 
The bowels are relaxed or confined. Often the disease is said to have 
begun with diarrhoea, and the attacks of looseness are sometimes separated 
by periods of more or less marked constipation. Nausea and vomiting are 
not such common symptoms in this form of peritonitis as the}*- are in the 
simple variety, and the appetite may be preserved for a considerable time. 

After some weeks the tenderness of the abdomen and its sensitiveness 
'to the slightest jar or shock, as well as the increasing weakness of the 
patient, obliges him to keep his bed. But he will sometimes go about as 
usual, if allowed to do so, for a long time — long after the disease is fully 
established. He may then be noticed to take very characteristic precau- 
tions to avoid jolting his belly when he moves. Thus, he will steady it 
with his hand as he walks ; and go backwards down-stairs, so that he may 



TUBERCULAR PERITONITIS — SYMPTOMS. 695 

more conveniently pass from step to step upon his toes. If the tempera- 
ture be taken at this time, it will be found to be higher than normal ; but 
the mercury seldom rises above 101° in the evening. In the morning it 
may be at the natural level. 

If the belly is examined, it will be found to be distended and oval in shape, 
the projection being more marked about the umbilicus and epigastrium 
than below the navel. The skin has often a shiny look ; the veins ramify- 
ing over the surface may be noticed to be full ; and the natural markings 
of the belly have disappeared. On palpation there is often increased ten- 
sion of the recti muscles, which contract instinctively to protect the tender 
peritoneum, and the resistance offered by the contents of the abdomen is 
very unequal. In some parts the parietes are easily depressed ; in others 
a certain feeling of solidity is conveyed to the finger, and distinct, firm 
masses may be often detected here and there. These are usually tender, 
and frequently pressure upon any part of the belly causes pain. In some 
cases free fluctuation can be detected. If there be pressure upon the por- 
tal vein by enlarged glands or caseous masses, the amount of ascites may 
be large. It is then often accompanied by oedema of the lower extremities 
and abdominal wall, with dilatation of the superficial veins of the belly. 
It is seldom, however, that these symptoms are noticed. Usually the 
amount of effused fluid is small, and there is merely an imperfect sense of 
impulse conveyed from one side of the abdomen to the other ; not a dis- 
tinct tap of the wave of fluid, such as we feel in the ascites accompanying 
cirrhosis of the liver. If the amount of fluid be small, or its consistence 
thick, no fluctuation may be discovered ; but in these cases it will be 
noticed that on percussing the belly the tympanitic note which prevails 
over the greater part of the abdominal wall changes in the flanks to dulness 
from the presence of fluid ; and that if the child be laid on one side, so that 
the fluid may gravitate downwards, the note on the flank turned upper- 
most becomes clear. 

Of these signs the most characteristic are : The enlargement of the 
belly, with its smooth, shining surface ; the tenderness, the unequal resist- 
ance at different parts of the abdominal parietes, and the indistinct fluc- 
tuation. In some cases, however, many of these symptoms may be absent. 
The tenderness may be insignificant and the parietes perfectly flaccid ; 
fluctuation may be completely absent; and nowhere may any sense of 
resistance be experienced by the hand pressing the abdomen. Thus, in a 
little boy of four years old, after three weeks of illness it was noted : 
" Abdomen large and smooth, with loss of natural markings ; superficial 
veins of chest and epigastrium dilated ; abdominal wall perfectly flaccid ; 
no fluctuation to be detected ; edge of liver felt one finger's-breadth below 
the ribs ; edge of spleen not felt ; several lumps about the size of a walnut 
can be perceived in different parts of the abdomen, but not very deeply 
placed. One of them is immediately below the edge of the liver. They 
seem tender on pressure, but there is no general tenderness of the belly. 
Chest healthy. Tongue dry and glazed-looking." The temperature that 
evening was 98.6°. The child died about a week after this note, of second- 
ary tubercular meningitis. If, in such a case, the liver be much enlarged 
from fatty infiltration, a very incorrect opinion is likely to be formed of 
the nature of the illness. 

As the disease progresses, the skin often gets very harsh and rough. 
The child looks haggard and distressed ; he rapidly wastes, and his temples 
and cheeks grow hollow. He lies on his back, or turned partly on to his 
side, with his knees drawn up, and every movement is painful. The 



696 DISEASE IN CHILDREN. 

tongue is dry, and is either thickly furred or is clean and shining, as if de- 
nuded of epithelium. The appetite is lost ; the thirst is great, and the 
bowels are generally relaxed. Often, the motions consist of dark, watery, 
offensive matter, with a flaky deposit containing black clots of blood. Such 
a stool is very characteristic of ulceration of the bowels. Instead of diar- 
rhoea, there may be constipation which may prove obstinate. Fatal ob- 
struction, even, may ensue. Sometimes at this period the distention of 
the abdomen becomes very great, and the child is tormented with spasms 
of colicky pain. In other cases, the size of the belly diminishes, and hard, 
tender lumps are felt, apparently in firm contact with the under surface of 
the abdominal parietes. The temperature, which before was variable and 
often little raised above the normal level, now becomes higher, and in the 
evening may reach to between 103° and 104°. The emaciation of the 
child is great, and his weakness extreme. 

When the disease reaches this stage, improvement rarely takes place ; 
but at an earlier period of the illness it is not uncommon for the malady 
to take a favourable turn. The tenderness and tension of the belly then 
diminish and disappear ; the appetite returns ; the diarrhoea ceases ; the 
nutrition of the child improves, and he begins to regain flesh. The fa- 
vourable change may go on in fortunate cases to complete recovery, and 
although the belly for a long time remains large, there is no return of the 
serious symptoms. Often, however, after a longer or shorter interval, the 
child begins to fail once more ; inflammation is lighted up again in his 
peritoneum, and this time the illness goes on uninterruptedly to the end. 

In some cases, the course of the disease is very variable, and is broken 
by occasional periods of remission in which hopes of amendment are raised 
only to be disappointed by an early return of the worst symptoms. Often, 
the end of the disease is preceded by purpuric spots on the body, and 
by oedema of the legs, with no albumen, or with only a trace of it, in 
the urine. Death may be hastened by tubercular disease of other organs, 
especially of the lungs, and sometimes, as in the case referred to, the pa- 
tient dies with all the symptoms of tubercular meningitis. In rare cases, 
perforation of the bowel takes place, or an abscess forms at the umbilicus 
or some other part of the abdominal wall. 

This chronic or sub-acute form of the disease is always slow in its 
course, and usually lasts several months. It is the form the disease as- 
sumes in the large majority of cases. Occasionally, however, the periton- 
itis is acute. In all the cases of acute tubercular peritonitis which have 
come under my notice, the abdominal disease has formed part of a general 
tuberculosis. The child complains of pain in the belly, but an exam- 
ination of the abdomen gives entirely negative signs. There is no ten- 
derness of the parietes, or pseudo-fluctuation ; no caseous lumps can be 
felt ; and the belly, although full, may not exhibit any remarkable swell- 
ing. The child looks ill, and is languid ; his appetite is poor, and his 
evening temperature is higher than natural. Often, his bowels are relaxed. 
These symptoms, as in all forms of acute tuberculosis, succeed to a period 
more or less prolonged, of general but indefinite malaise. After an illness 
lasting a few days or a week or two, the child dies, with or without the 
symptoms of meningitis. After death, his bowels are found matted to- 
gether with recent lymph ; there is, perhaps, a little thin purulent fluid in 
the peritoneal cavity, and the signs of general tuberculosis are discovered 
over the body. In most cases, the existence of the peritonitis is only re- 
vealed by post-mortem examination. 

A boy, aged four years, was under the care of my colleague, Dr. Donkin, 



TUBERCULAR PERITONITIS— SYMPTOMS — DIAGNOSIS. 697 

in the East London Children's Hospital. The child was said to have been 
ill for two weeks. He had first complained of pain in the belly, which 
was full and distended, and his bowels were relaxed. The pain was attrib- 
uted by the mother to wind, for*it was relieved by hot grog. The loose- 
ness of the bowels ceased after a day or two, but the boy remained weak 
and listless ; his feet swelled a little when he sat up, and his face was 
noticed to be puny in the mornings. For two or three days before admis- 
sion he had had a slight cough. 

"When the boy came into the hospital his face was a little puffy about 
the eyelids and bridge of the nose. The heart and lungs appeared to be 
normal. His belly was distended, but there were no dilated superficial 
veins ; no dulness was noted on percussion in either flank ; no enlarged 
glands or fluctuation could be detected ; no pain or tenderness was com- 
plained of ; and the liver and spleen were of normal size. There was a 
little oedema of the scrotum, but none of the lower limbs. His urine was 
scanty, but there was no albumen. Pulse, 88, regular ; temperature, 98° ; 
respirations normal. After a few days, as the temperature was natural, and 
the boy was up and about and seemed convalescent, there was a question 
of sending him home. Before this could be done, however, a sudden 
change took place in his condition. He became very drowsy, and was 
forced to return to his bed. He then began to vomit ; his pulse was 80 
and intermittent : his temperature rose again, and he seemed at times to 
be only half conscious. Three days after his return to his bed, the boy 
had an attack of convulsions ; his temperature went up to 108°, and he 
died. On examination of the body, there was found a basic meningitis 
with many gray granulations in the cranium. Similar granulations were 
seen on the pleurse. The peritoneum, both parietal and visceral, was pro- 
fusely studded over with gray and yellow granulations, varying in size 
from a pin's head to a pea ; and there was much recent lymph, which 
had matted together the coils of intestine, and fixed them with the omen- 
tum to the abdominal wall. There was no excess of fluid in the peritoneal 
cavity. 

Such a case is very perplexing. The only symptoms pointing to the 
abdomen are the abdominal swelling and pain ; but these alone, in the 
absence of tension and tenderness of the parietes, or other equally charac- 
teristic symptom, are insufficient to establish the diagnosis of peritonitis. 
Pain in the belly is a symptom so frequently met with in the child that its 
occurrence excites little remark ; and a large belly in young subjects is 
not sufficiently uncommon to attract special attention. Still, if we are 
aware that the illness may run this rapid course, such symptoms, taken in 
connection with the general weakness, the slight oedema without albumi- 
nuria, and the terminal manifestations of cranial disease, may justify us in 
at least suspecting the existence of the abdominal complication. 

Diagnosis. — In ordinary cases, the diagnosis of tubercular peritonitis is 
easy. Inflammation of the peritoneum developing slowly and insidiously, 
accompanied by rapid wasting and a very variable temperature, and pre- 
ceded by general impairment of nutrition and abdominal pain, is very 
suspicious of tubercle. We must remember that tenderness and tension 
of the abdominal wall may be little pronounced, and that fluctuation is 
often absent, or, if present, is usually imperfect and indistinct. A definite 
tap readily transmitted through the fluid from one side of the abdomen to 
the other, although met with in rare cases of tubercular peritonitis, is yet 
not at all characteristic of this disease. Indeed, if such free fluctuation be 
present in a child who is lively and fairly active, it tells rather against than 



DISEASE IN CHILDREN. 

in favour of the diagnosis. In doubtful cases, it is desirable to test the 
effect of a sudden jar upon the child. If he be made to jump down to the 
ground from a low chair, and experience no uneasiness from the little 
shock, it is improbable that the peritoneum is inflamed. A child with 
abdominal tubercular disease is invariably dull and listless from the 
earliest period of the disease. He looks ill from the first ; and although 
he may be fairly stout, there are usually signs that his nutrition is already 
impaired. These symptoms are of great importance when combined with 
abdominal pain, swelling, and tenderness. Chronic digestive derange- 
ments are common in early life, and I have known children who have been 
habitually overfed with farinaceous food, to be subject for months together 
to attacks of abdominal pain, often of great severity. But such children 
are lively and active enough ; although pale and often flabby, they do not 
look ill ; they have not the careworn, haggard expression which is almost 
inseparable from serious disease at every period of life ; and although the 
abdomen may be full and sometimes painful, the fulness is variable, often 
subsiding completely ; there is no tenderness or involuntary tension of 
the parietes, and the temperature is that of health. Such cases are easily 
cured. Limiting the consumption of farinaceous matters, a gentle aperient, 
and an alkaline aromatic mixture, will soon put an end to the indisposi- 
tion. 

The acute form of tubercular peritonitis is often puzzling, especially 
if, as in the case referred to above, the abdominal symptoms are limited to 
some swelling and pain. In such a case, typhoid fever is often suspected, 
and the pyrexia, wasting, and increasing weakness may seem to give 
strength to this opinion. No evidence is to be derived from the state of 
the bowels ; for whether confined or relaxed, either condition is perfectly 
compatible with enteric fever. Even if more distinct evidences of peri- 
tonitis occur, these may be attributed to perforation and consequent in- 
flammation. Still, the absence of rash and of splenic enlargement, the 
comparatively moderate pyrexia, and the more haggard aspect of the 
patient are not in favour of typhoid fever ; and if fluctuation can be de- 
tected in the abdomen, or slight oedema of the legs and face is noticed, this 
disease may be at once excluded. 

Prognosis. — Tubercular peritonitis is not invariably fatal, and there- 
fore we should not at an early period of the illness act as if the case were 
a hopeless one. Tension and tenderness are important symptoms, and if 
the child lies in one position, with his knees raised, apprehensive of the 
least movement, the sign is not of favourable import. A profuse diarrhoea 
or the passage of stools indicating ulceration of the bowels must be viewed 
with apprehension. If the tenderness is extreme, and solid tubercular 
masses can be felt underneath the abdominal parietes, recovery, although 
possible is very unlikely. Also, the presence of signs indicating tuber- 
cular disease of other organs is of course to be taken as of serious omen. 

On the other hand, increased regularity in the stools, improvement of 
appetite, reduction of pyrexia, diminution or subsidence of abdominal ten- 
derness, and return of cheerfulness are all encouraging signs. We must 
remember, however, that alternations of improvement and relapse are 
common in this disease, and that recovery, although not exactly uncommon, 
is, at any rate, an exceptional termination to the illness. 

Treatment. — Absolute rest, hot applications to the abdomen, and opium 
internally, form the most useful means at our disposal for promoting the 
subsidence of the disease. The child should be put to bed, and his belly 
should be kept covered with hot linseed-meal poultices, frequently re- 



TUBERCULAR PERITONITIS— TREATMENT. 699 

newecl. If the weight of these be complained of, and there is much pain 
and tenderness, great relief is often derived from smearing the surface 
with a salve composed of extract of belladonna and glycerine in equal pro- 
portions, and covering this with a thick layer of cotton-wool. The child 
should take a draught containing a few drops of laudanum every night, 
and if his stomach will bear it, cod-liver oil may be administered. Diar- 
rhoea should be treated with full doses of bismuth and a drop or two of 
tincture of opium two or three times a day ; or three or four grains of ex- 
tract of hseraatoxylum may be combined with three drops of laudanum 
and three of ipecacuanha wine in a chalk mixture for a draught to be 
taken several times in the twenty-four hours. Purging will also be re- 
lieved by a small injection of starch and laudanum, given at night. If 
there be constipation, it is better to avoid aperients and trust to injections 
to relieve the bowels. When necessary, the accumulation can be cleared 
away by a good enema of soap and warm water. 

The diet of the child should be regulated to suit his powers of diges- 
tion. Strong beef-tea and other broths, milk, yolk of egg, minced mutton 
or chicken, fish, bread and butter, and light pudding should be given. 
But great attention should be paid that excess of farinaceous matter is 
not allowed, as acidity and flatulence will increase the discomfort of the 
patient and be decidedly injurious. A stimulant is required as the strength 
begins to fail. The brandy-and-egg mixture of the British Pharmacopoeia 
is the best form in which this can be administered. 



CHAPTER XIV. 

ASCITES. 

An accumulation of fluid is sometimes met with in the peritoneal cavity 
in the child as a result of various causes, and it is not always easy to refer 
the symptom to its true origin. 

Causation. — In childhood, as in after life, ascites may be the consequence 
of peritoneal inflammation ; of obstruction to the flow of blood through the 
portal vein ; and of causes which influence the systemic circulation. 

In peritonitis the quantity of fluid is rarely great, and sometimes it is 
so small that it is with difficulty detected. Even in the subacute perito- 
nitis which is the result of tuberculosis of the serous lining of the abdomen, 
there is rarely great excess of fluid. In both cases, the symptoms connected 
with the belly may be so little characteristic that the disease passes com- 
pletely unnoticed, and is only discovered after death. 

The circulation of blood through the portal vein may be obstructed by 
causes which act within the liver substance or affect the venous channel be- 
fore its entrance into the organ. Cirrhosis of the liver may cause great im- 
pediment to the portal circulation ; and there is every reason to believe 
that this form of disease is less uncommon in the child than was at one time 
supposed. So, also, hepatic induration resulting from congestion of the or- 
gan may be attended by the same result. A hydatid of the liver, if placed 
near to the concave surface of the gland, may cause sufficient interference 
with the flow of blood from the abdominal viscera to lead to serous effusion. 
In the rare cases in which the liver is the seat of a malignant disease, ascites 
may also occur ; and I have known it to be produced by syphilitic gum- 
mata of the liver in a young baby. 

Of causes lying outside the liver, the most common is the presence of a 
mass of caseous glands in the hepatic notch. This will press upon the por- 
tal vein as it enters the transverse fissure. Pressure may also be exercised 
upon the vein by malignant or lymphomatous growths of the mesentery, 
but these are very rarely met with. 

Of the causes which act through the general circulation, heart disease 
takes the first place. It is common in cardiac lesions to find ascites com- 
bined with general cedema, and very often serosity is poured out, not only 
into the peritoneum and subcutaneous tissue, but also into the pleural cavity. 
Disease of the lungs seldom gives rise to ascites in young subjects ; and in 
cases of Bright's disease, although general dropsy is common, abdominal 
effusion is more rarely seen. Extreme ansemia is sometimes attended by 
ascites, but this is not a frequent result of mere impoverishment of blood. 

Symptoms. — In a marked case of ascites, the belly is distended and 
globular. As the child lies on his back the outline of the abdomen is more 
rounded than in the erect position, for the fluid gravitates and tends to col- 
lect in the flanks and swell them out. The skin of the belly is smooth and 
shining, and may be tense. The umbilicus is generally prominent, and often 



ASCITES — SYMPTOMS. 701 

the superficial veins of the abdominal wall are unnaturally visible. When 
the observer places his hands one on each side of the belly, a slight tap 
of the finger sends a distinct impulse through the fluid to strike against 
the hand in contact with the opposite wall of the abdomen. This sense of 
fluctuation is not stopped by pressure made in the middle line of the belly. 

On percussion, the note is clear over the upper part of the belly, and 
dull in the flanks. The dulness varies according to the position of the 
child, as the fluid always sinks to the most depending part of the abdomi- 
nal cavity. Consequently, the side turned uppermost always gives a reso- 
nant note. If the amount of fluid be very large, the dulness may be general, 
except, perhaps, over the region of the stomach and transverse colon. In 
such cases there is usually dyspnoea from interference with the action of 
the diaphragm ; and this is often so distressing that the child cannot lie 
down in his bed. It may be accompanied by a certain amount of collapse 
of the bases of the lungs. The pressure of the accumulated fluid may also 
set up oedema of the lower extremities and genitals, and this quite irrespect- 
ive of cardiac disease. 

In ascites, although excess of fluid will excite discomfort and distress, 
there is seldom actual pain unless the peritoneum be inflamed. Still grip- 
ing pains may be sometimes complained of. These are due probably to 
the interference with digestion set up by the congested state of the gastric 
and intestinal mucous membrane. For the same reason, looseness of the 
bowels is a not uncommon symptom. The appetite is often good; the 
tongue is usually clean ; and, in non-inflammatory cases, the temperature is 
that of health. Often the skin is dry and the secretion of urine scanty, high- 
coloured, and perhaps albuminous. 

Other symptoms may be present, according to the disease of which the 
peritoneal effusion is the consequence. If there be peritonitis, the tempera- 
ture is generally elevated, and, in ordinary cases, there is tenderness of the 
belly with abnormal tension of the wall. We must not, however, always 
expect such definite signs. As described elsewhere, peritonitis, like pleurisy 
and pericarditis, may be completely latent, accompanied by none of the 
characteristic phenomena by which its presence is usually revealed. In 
peritonitis the amount of fluid is small, as a rule ; and fluctuation is often 
far from being distinct. A scanty secretion may gravitate into the pelvis 
and thus escape detection on superficial examination ; or may be retained 
in the coils of intestine by adhesion of the coats of the bowel to one an- 
other. Evidence of fluid may, however, be often obtained by placing the 
patient for some minutes on his side, according to the plan advocated by 
Duparcque. The effusion will then gravitate into the undermost flank. 
Afterwards, by turning the child quickly on to his back and examining the 
region lately depending, dulness and signs of fluctuation will be often dis- 
covered before the fluid sinks away again from the surface. Another plan 
is to place the child upon his elbows and knees ; the fluid then gravitates 
to the umbilical region and gives the usual evidence of its presence. 

In cases of hepatic cirrhosis, the peritoneal effusion is usually copious, 
and fluctuation very distinct. The spleen, in these cases, is often en- 
larged ; signs of digestive disturbance are noted ; the skin, in advanced 
cases, has an earthy tint, or may even be jaundiced ; the veins of the ab- 
dominal wall, especially in the umbilical region, are unnaturally prominent ; 
and signs of dilated haemorrhoidal veins, even in young subjects, may be 
sometimes detected. 

When the ascites is due to cardiac disease, there is general anasarca ; 
the lips are bluish and the complexion livid ; the jugular veins are full 



702 DISEASE IN CHILDREN. 

and pulsating, and often fill from below ; the breathing is oppressed. The 
urine is scanty and albuminous ; effusion into the pleural cavities may be 
perhaps discovered, and an examination of the heart at once reveals the 
cause of the obstructed circulation. 

Diagnosis. — A large belly is no sign of ascites. The abdomen in a 
young child is always relatively large as compared with the rest of his 
body ; and if the child be the subject of rickets, or be injudiciously fed, 
or suffer from looseness of the bowels, the disproportionate size of his belly 
is still further exaggerated. Flatulence is the commonest cause of abdom- 
inal distention in the child, and the increase in size from this reason is 
sometimes so great as to excite serious alarm in the minds of the parents. 
It is very common in rickety children who habitually suffer from derange- 
ment of the bowels and consequent fermentation of food. In this dis- 
tress, the flatulent distention is rendered more conspicuous by the relaxed 
state of the abdominal muscles and the shallowness of the pelvis. Often, 
in these cases, on palpation of the belly, an indistinct sense of fluctuation 
may be felt between the hands, placed on either flank. This is conveyed 
through the distended bowels. It is distinguished from the impulse con- 
veyed by a wave of fluid by the effect upon it of pressure made in the mid- 
dle line of the abdomen. If fluid be absent, the tap of the finger will then 
at once cease to be felt by the hand placed on the opposite side of the 
belly. 

Enlargement of the abdominal organs may also determine the disten- 
tion of the belly. Congestion, amyloid and fatty degenerations, hydatid 
disease, and hypertrophic cirrhosis of the liver ; a spleen enlarged from 
amyloid disease, rickets, or ague ; a kidney the seat of sarcoma or hydro- 
nephrosis ; cancerous or lymphomatous growths from the omentum or ab- 
dominal glands — in all these cases the size of the belly may be increased. 

The only test of ascites is the presence of fluctuation. This, if the 
amount of fluid is small, can often be obtained by placing the patient in 
such a position that the fluid may gravitate to the surface and thus be 
brought within reach of the fingers. It is not enough, however, to detect 
the presence of ascites. We have to ascertain, if possible, the cause to 
which this excess of fluid is owing. If the symptoms of the determin- 
ing disease are well marked, the diagnosis may be easy. If, however, the 
symptoms are obscure, the case may present great difficulty, and often it 
is impossible to arrive at a positive conclusion. 

A little girl, aged seven 3 r ears, of healthy parentage, was a patient in 
the East London Children's Hospital. The child had passed through mea- 
sles and whooping-cough, and between two and three years previously had 
had an attack of scarlatina which was followed by dropsy ; but this had 
been completely recovered from. There was no rheumatic tendency in the 
family, and the girl herself had never suffered from rheumatic pains, but 
she was said to be subject to bilious attacks. 

Six weeks before her admission she had begun to complain occasionally 
of feeling cold, and used to come back from school saying she had a head- 
ache. She also occasionally complained of pains in the right side of the 
abdomen, and. sometimes vomited. After these symptoms had continued 
for a fortnight, the pains became more severe and paroxysmal, and the 
belly began to swell. From that time she lost flesh. Her appetite had 
been pretty good, and the bowels usually regular ; but she had had two or 
three attacks of diarrhoea, lasting on each occasion twenty-four hours. 
For two or three days before admission she had had attacks of shivering. 

When first seen, the girl was in fair condition, and, although pale, had 



ASCITES — DIAGNOSIS — PROGNOSIS. 703 

no distressed expression of face. Her lips were pink. There was no yel- 
lowness of the sclerotics. The skin was a little dry, but not harsh or 
rough. The belly was very full and tense-looking. Its girth was 27^- 
inches. It fluctuated freely, and the veins of the parietes were unusually 
visible. The lower edge of the liver could not be felt ; its upper border 
was in the fourth interspace. The spleen was estimated by percussion 
(the child lying on her right side) to reach from the seventh to the ninth 
rib. There was no tenderness of the belly. The heart's apex was be- 
tween the fifth and sixth ribs, and the precordial dulness reached upwards 
to the second rib. On auscultation, a distinct rub was heard with the sys- 
tole and between the two sounds at the mid-sternal base. The lungs were 
healthy, except for a little sub-crepitant rhonchus at the bases, which dis- 
appeared in a great measure after a cough. The child was thirsty, but 
had little appetite ; her tongue was clean and rather red. Pulse, 128 ; 
very intermittent, weak and soft. Her bowels acted regularly every day, 
and the motions had a natural appearance. The urine was very clear and 
pale. It was acid ; had a density of 1.015, and contained no albumen or 
bile pigment. The temperature on the morning after admission was 103°, 

During the next three weeks the temperature continued to be febrile ; 
the physical signs in the chest became more developed, and the child 
passed through a well-marked attack of pericarditis with effusion. As the 
pericardial fluid became absorbed, the ascitic effusion began also to dis- 
appear and the abdomen to diminish in size. In four weeks from the 
time of admission, the child was convalescent and was discharged. About 
a month afterwards she was readmitted with an attack of well-marked 
enteric fever. It is curious that during this illness the ascites and peri- 
carditis both returned ; but they subsided again, as before, during con- 
valescence from the fever. Eventually, the girl recovered her health com- 
pletely. 

The cause of the ascites in this case is not very clear ; but the absence 
of all symptoms pointing to the liver, combined with the natural size of 
the spleen, seemed to exclude cirrhosis. The history suggested peritonitis, 
and although the characteristic features of this disease were absent, such 
absence is occasionally -observed. Taking into account the previous 
symptoms, the high temperature, the occurrence of pericarditis as if from 
extension of the inflammation, and the completeness of recovery, this view 
would seem to furnish the most probable explanation of the child's illness. 

In some cases, fluid may be present in the abdomen from other causes 
than ascites. Thus, a large hydronephrosis which almost completely fills 
up the cavity of the belly, may be accompanied by free fluctuation, evidently 
due to fluid ; and it may not be easy to distinguish this condition from a 
copious peritoneal effusion. On careful examination, however, it will be 
usually found that in hydronephrosis the swelling of the abdomen is not 
quite symmetrical, but that the flank on one side shows a greater promi- 
nence than on the other. The resistance is also greater over the site of the 
greatest bulging ; and although, as the child lies on his back, the umbilicus 
is absolutely dull, a spot can often be discovered in the less prominent 
flank where a clear percussion-note is obtained. Lastly, tapping the 
swelling will withdraw a fluid containing urea. 

Prognosis. — In cases of ascites, the child's prospects depend less upon 
the amount of fluid effused into the abdominal cavity than upon the cause 
of the phenomenon and the general symptoms by which the effusion is 
accompanied. Causes which affect the system generally, or impede the 
flow of blood through the portal vein as a consequence of obstruction to 



704 DISEASE IN CHILDREN. 

the general circulation, are especially to be feared. Thus, ascites from 
tubercular peritonitis, or from heart disease, is a symptom of serious 
import. In all cases, the prognosis depends chiefly upon the pathological 
condition which has occasioned the escape of serosity. If this cannot be 
discovered, we must judge of the prognosis by remarking the state of the 
child's strength, his temperature, and his pulse ; and by noting the degree 
of efficiency with which the skin and the other emunctories of the body 
are performing their functions. The skin in particular is an important 
guide. If the temperature is not elevated, the urine non-albuminous and 
of normal density, and the skin of natural tint, and neither dry nor harsh, 
we may speak favourably of the child's chances of recovery. 

Treatment. — The treatment of ascites is dependent upon the illness in 
the course of which the symptom has arisen. If peritonitis (simple or 
tubercular) be present, the special measures recommended in the chapters 
relating to those diseases must be resorted to. If the ascites form a part 
of general dropsy dependent upon heart disease, it will be relieved by the 
diuretics, purgatives, and cardiac tonics and stimulants which are found 
efficacious in that serious condition. 

In cases of ascites of obscure origin, or dependent upon disease of the 
liver, iron and other tonics have often a marked influence in reducing the 
amount of fluid in the peritoneum and improving the general condition of 
the patient. The exsiccated sulphate of iron is well borne by children, 
and may be given three times a. day, in doses of five grains, to a child of 
three or four years of age. The tincture of the perchloride of iron with 
quinine is also useful ; but whatever form of chalybeate is used, the dose 
should be a large one. Violent purgatives are to be avoided, but consti- 
pation must be treated by suitable doses of compound liquorice powder, 
compound jalap powder, or, if at the beginning of the treatment, by a grain 
of calomel followed by a saline. The action of the skin must be main- 
tained by a daily tepid or warm bath ; and the child should be dressed in 
woollen underclothing from head to foot. 

If the accumulation of fluid be copious, paracentesis should be per- 
formed without hesitation ; and it is now generally held that promptness 
in the performance of this operation is to be preferred to delay. The diet 
of the child, as in all forms of chronic disease, should be arranged accord- 
ing to the state of his digestion ; and a watch should be kept over his 
capacity for digesting starch, sugar, and all forms of fermentable food. 
An excess of such matters would encourage flatulence and colicky pains, 
and must therefore be avoided. 



CHAPTER XV. 

INTESTINAL WORMS. 

Of the many varieties of parasitic worms which infest the alimentary canal 
in childhood, three only are of special practical importance from giving 
rise to disturbance or distress. These are : — The small thread-worm, the 
long round-worm and the tape-worm. There is one other, the large 
thread- worm (tricocephalus dispar), which is also occasionally met with ; 
but the creature seems to give rise to no symptoms, and is only discovered 
by its presence in the stools. 

Description. — The small thread-worm (oxyuris vermicularis), often called 
seat-worm, belongs to the order nematoda. To the naked eye, these worms 
have the appearance of fine white threads. Both female and male speci- 
mens exist together, the former being the larger. In both sexes the an- 
terior part of the body is of fusiform shape. It is narrowed towards the 
head, which is abruptly truncated and provided with three tubercles. The 
male is one-sixth of an inch in length. Its intestinal tube extends the 
whole length of its body, and terminates in the anus at about the middle 
of the tail. The tail is arranged in a spiral form. The penis is minute 
and hook-shaped. The female measures nearly half an inch in length. 
Its body ends in a long tapering tail, which is three-pointed at the end. 
Under the microscope its uterine ducts can be seen to contain a multitude 
of ova. The eggs are long and unsymmetrical. They may be readily 
hatched by exposing them to the sun in a moistened paper envelope, as in 
the experiments of Vix and Leuckart. When this is done, tadpole-shaped 
embryos escape at the end of five or six hours, and rapidly develope 
into slender worms. It appears from the researches of Leuckart and 
Heller that the embryos can escape from the ova in the human body. Hel- 
ler states that their liberation takes place in the stomach under the 
influence of the gastric juice. From the stomach the creatures pass into 
the duodenum and upper bowel, growing rapidly as they descend the ali- 
mentary canal ; and by the time they reach the caecum have arrived at 
sexual maturity. 

According to Dr. Cobbold, the caecum is the customary habitat of these 
parasites ; but they have a tendency to migrate, especially into the sigmoid 
flexure and lower rectum, and can often be seen moving about in the 
folds of the anus. 

The long round-worm (ascaris lumbricoides), often called lumbricus, is 
a large nematode worm of a yellowish red colour. The female is fifteen 
inches, and the male ten inches in length. The body is cylindrical, taper- 
ing to either extremity, but more rapidly towards the head. The mouth is 
triangular, having three lips. It is armed with numerous (about two hun- 
dred) microscopic teeth. The alimentary canal is simple, without division 
between stomach and intestine. The tail is conical and pointed. In the 
male it is curved like a hook towards the ventral aspect of the body ; in the 
45 



706 DISEASE IN CHILDKEN. 

female it is straight. The eggs, which are excessively numerous in each 
female specimen, are oval in shape, and have a thick, firm, elastic, brownish 
shell, which is usually nodulated on the surface. In these ova, the embryos 
develope very slowly, for Davaine kept some alive for five years without 
perceiving any attempt of the immature tenants to escape from the shell. 
These embryos have a curious tenacity of life, for they cannot be destroyed 
by frost or complete desiccation. It has been doubted whether the eggs 
can be hatched, and the embryos escape and pass through their develop- 
mental stages to maturity, in the alimentary canal of the subject infested 
with them. It appears, however, from the researches of Heller that this is 
possible. 

The lumbricus inhabits the smaller bowel, but is migratory in its habits, 
and has a peculiar tendency to wander. The worms have been consequently 
found after death in very curious places. They have been seen in the nasal 
passages ; in the larynx and bronchi ; in the ducts of the liver and pancreas ; 
in the gall-bladder, and even in the cavity of the peritoneum, and in the 
interior of abscesses communicating with the abdomen. The worm has no 
power of penetrating the living tissues, but can pass through an ulcerated 
surface. Thus, it has been known to pass through an ulcerating lesion of 
the vermiform appendix, and set up peritonitis by entering the cavity of 
the abdomen. 

The tape-worm is a flat, jointed worm which belongs to the order ces- 
toda. Several varieties of this parasite may be found in the human subject. 
The most common is the taenia medio-cannellata (the beef tape-worm). The 
taenia solium (the pork tape-worm) is also met with. The bothriocephalus 
latus, another species, is not common in the British Islands, although it is 
less rare on the continent of Europe. There are other varieties, but these, 
as they are very seldom seen, need not be here considered. 

All these worms are flat, segmented creatures, destitute of mouth or ali- 
mentary canal. They grow from the head, which developes a continuous 
linear series of new joints by a budding process. The joints are quadri- 
lateral in shape. They are at first immature, but as their distance from 
the head increases, they become larger and more developed. Strictly 
speaking, the tape-worm is not a single parasite, but a community of indi- 
vidually distinct creatures, of which only the lower or older members (pro- 
glottides) are sexually complete. These contain each their own organs of 
generation, both male and female. 

Between the T. medio-cannellata and the T. solium, the difference is 
■chiefly in the shape of the head. In each, the neck is tapering and thread- 
like, and about an inch in length. This passes gradually into the anterior 
jpart of the body, which is sexually immature, and is not distinctly jointed. 
By degrees the transverse lines, which mark the imperfect divisions of the 
young segments, become more defined and more widely separated, so that, 
while the more recent segments, or those nearest to the neck, are much 
wider than they are long, the older joints, as they become more and more 
mature, grow to be much longer than they are broad. Each mature seg- 
ment (or proglottis) is about half an inch long by a quarter of an inch 
broad. It contains an elongated, tubular uterus, branched on either side ; 
and the male and female organs of generation open by a common perfo- 
rated papilla, which is placed at the border below the middle line, on one 
side or the other, but not in regular alternation. In a worm eight feet long, 
the total number of joints has been reckoned at about eight hundred ; but 
it is not until near the four hundred and fiftieth segment from the head 
that the joints begin to be sexually mature. The head is globular, and 



INTESTINAL WORMS—- DESCRIPTION— CAUSATION. 707 

about the size of the head of a small pin. In the T. solium, it forms in 
front a short cylindrical proboscis (rostillum) having four projecting suckers 
decorated by a crown of twenty-six booklets. In the T. medio-cannellata 
there is no crown of booklets or proboscis ; but the suckers are large and 
prominent, and there is usually a fifth smaller one in the ordinary position 
of the rostillum. 

These worms often grow to a great length and may measure many 
yards. They infest the small intestine and may number one or more in 
the same subject. The eggs, which are very numerous, he in the uterine 
ducts of the mature segments ; and each contains an embryo which, in the 
case of the taenia solium, is furnished with three pairs of booklets. 

The mode of development of the creature is as follows : — The taenia, 
unlike the other worms which have been described, does not pass through 
all the stages of its growth from the ovum to maturity in the body of the 
same individual, for the embryo does not develope directly into the perfect 
worm. There is a transitional stage which requires to be completed in the 
body of an intermediary. This agent is usually an animal. Thus, when 
a ripe joint filled with ova is eaten by an animal, it passes into the stom- 
ach. There, the eggs are ruptured, and the embryos (pro-scolices) escape. 
These embryos have a tendency to perforate the tissues of the animal by 
whom the}- are harboured. They may thus make their way into the cellular 
tissue of a muscle, into the liver or the brain. Thus sheltered, they pass 
through a metamorphosis, and become the cysticercus or bladder-worm. 
The cysticercus cellulosse of pork consists of a cyst-like body, with a head 
and neck like those of the fully-developed worm. These are usually in- 
verted within the body. As long as the cysticercus is unmolested it under- 
goes no further change ; but when the flesh of the animal is eaten imper- 
fectly cooked, so that the vitality of the cysticercus is uninjured, the 
creature at once adapts itself to its new situation, and attaching itself 
to the wall of the small intestine, developes in the course of a few months 
into the perfect tape-worm. 

The bothriocephalus latus, in its general appearance, resembles the two 
varieties of taenia just described, but is rather larger and may grow to a 
greater length. The mature joints are broader than they are long, and the 
sexual openings are placed, not at the side of the segment as in the taenia, 
but in the middle of the joint, where they appear as rosette-shaped patches. 
This tape-worm, like others, has an intermediate or larval stage ; and it 
had long been suspected that its ciliated embryo found shelter in the body 
of some aquatic animal. Dr. Braun, of Dorpat, has lately found the early 
asexual form of the bothriocephalus encapsuled in the intestine of the pike, 
and also in some of the muscles, in the liver, and in the spleen of the same 
fish. Dr. Braun gave these organisms experimentally to dogs and cats, 
who were put on a strict diet and allowed only distilled water for drink. 
As a consequence, segments of the bothriocephalus began quickly to appeal* 
in the faeces of the animals. 

Causation. — The means by which thread-worms gain access to the 
human body, is by the direct passage of the ova into the mouth. The eggs 
are often introduced clinging to fruit, cresses, and various articles of food. 
But they may also be directly conveyed to the mouth by the patient him- 
self. It has been said that the embryo is liberated from the egg in 
the child's stomach by the action of the gastric juice upon the ovum. It 
has been also stated that each individual female worm contains in itself a 
multitude of eggs which pass out in large quantities with the stools. The 
embryos are probably not liberated from the ova in the bowels ; but if the 



708 DISEASE IN CHILDEEN. 

ova are re-introduced into the alimentary canal by the mouth, they become 
exposed to the action of the gastric juice in the stomach, and their contents 
may be set free. According to Dr. Cobbold, children frequently carry the 
ova under their nails ; for the irritation to which the presence of the oxy- 
ures gives rise, obliges them to seek relief by scratching. In this way the 
eggs may be transferred directly to the mouth. 

The ova of the lumbricus appear to be imported through the medium 
of impure water. This parasite is said to be especially common in low- 
lying, marshy districts. 

In the case of the tape-worm, it is through the eating of imperfectly 
cooked flesh infested with the cj'sticercus that an individual becomes the 
unwilling harbourer of the parasite. The taenia solium is derived from 
measly pork ; the taenia medio-canellata from beef. In children who suf- 
fer from a chronic looseness of the bowels, and are consequently fed with 
pounded raw meat, tape-worm is occasionally met with. 

Symptoms. — The most varied symptoms have been ascribed to the 
presence of worms in the bowels. Most of these are doubtless due to the 
intestinal derangement from which the patient is commonly suffering. 
That they are not a necessary consequence of the visits of these parasites 
is shown by the fact that it is not rare for the creatures to be found in the 
stools of children who have not previously exhibited any sign of discom- 
fort or distress. In these cases, the worms are usually few in number, and 
can be readily got rid of by the administration of an ordinary aperient. 
It seems necessary for the extensive propagation of the entozoa that a ca- 
tarrhal condition of the bowel should be present. In the secreted mucus 
the embryos find a favourable medium for development, and if, as often 
happens, the flux be profuse, great difficulty may be experienced in free- 
ing the patient from these irritating pests. It is in such cases only that 
severe general symptoms are found ; but these, as has been said, are to be 
rightly attributed, not to the parasites, which may be looked upon as acci- 
dental complications, but to the unhealthy state of the alimentary mucous 
membrane, which hinders digestion and impairs the nutrition of the body. 
These symptoms are described elsewhere (see page 121), and need not be 
here repeated. There are, however, many special symptoms which are at- 
tributed directly to the presence of worms ; and as they are not necessarily 
the consequence of the intestinal derangement referred to, and often cease 
when a number of worms have been expelled, it is possible that they are 
really due to the irritation set up by the creatures in the bowels. 

Most of these special symptoms will be referred to in describing the 
particular symptoms produced by the several species of worm. It may, 
however, be stated in this place, that every variety of nervous symptom, 
from headache, and other disorders of sensation, to spasm, paralysis, and 
convulsions, has been found associated with the presence of worms in the 
alimentaiy canal. Some of these have been looked upon as pathogno- 
monic. ' Thus, Dr. Underwood held that an attack of convulsions, accom- 
panied by small pulse and hiccough, was an almost certain sign of worms. 
Monro was of opinion that unequal dilatation of the pupils pointed posi- 
tively to the same conclusion. Others have relied upon the rapidity and 
irregularity of the pulse as furnishing sufficient grounds for the diagnosis. 
It cannot be denied that these symptoms may be noticed in children suf- 
fering from intestinal worms, and may possibly be produced by them ; but 
similar symptoms are found in cases where careful observation fails to dis- 
cover any sign of the creatures or their ova in the stools. 

There is one symptom which, although not positively distinctive of the 



INTESTINAL WORMS— SYMPTOMS. 709 

irritation of worms in the bowel, renders the presence of the parasites 
highly probable. This symptom is a peculiar appearance of the tongue. 
In all cases where the bowels are the seat of a mucous flux, the tongue gives 
evidence of this condition. It is flabby, and indented at the edges by the 
teeth. The increased secretion of mucus in the mouth gives to the tongue 
a slimy, gummy appearance. The lingual surface is covered with a thin 
coating of gray fur, and the fungiform papillae at the sides of the dorsum 
peer through the fur as round or oval spots, which are more or less red, 
according to the degree of irritability of the stomach. In cases where 
worms are present, I have often remarked a peculiar fawn colour of the 
fur covering the dorsum, and the slimy appearance of the organ has been 
especially noticeable. 

A child may be infested by more than one variety of worm at the same 
time. It is not uncommon to find round-worms together with thread- 
worms ; and sometimes round-worms and tape-worms are present at the 
same time in the same subject. Thus, a little boy, aged one year and eight 
months, was under my care for tape-worm, from which he had been suffer- 
ing for three months. This child, on one occasion, passed a large round- 
worm and many joints of the taenia in the same stooL 

In the case of thread-worms, the patient seldom complains of abdominal 
pain, but the irritation set up in the rectum by the presence of the entozoa 
gives rise to a troublesome itching of the fundament, which in sensitive 
children may cause an extreme degree of suffering. This irritation comes 
on towards the evening, and at night may be so distressing that sleep is 
greatly interfered with. In some cases, in addition to the itching, shoot- 
ing pains may be complained of in the same part. Catarrh of the rectum 
is not uncommon in such subjects. There may be looseness of the bowels, 
and the evacuations are often discharged with straining efforts. They may 
be followed by prolapse of the rectum. The stools often contain glairy 
mucus, and sometimes blood in streaks, or even clots of considerable size. 
Difficulty in emptying the bladder may be a consequence of the irritation, 
and the child sometimes holds his water for many hours together. Itch- 
ing of the nose, a leaden tint of the lower eyelid, and swelling of the upper 
lip, are also very common symptoms when thread-worms are present. 

The worms are readily detected as white moving threads in the stools, 
and may be seen in the folds of mucous membrane about the anus. They 
may pass or be conveyed into the vagina in little girls ; and can often be 
discovered in the bed-clothes. A microscopic examination cf the stools 
usually discovers a multitude of ova. 

The lumbricus, on account of its large size and its habits of nocturnal 
activity, is a cause of considerable irritation. This worm is said frequently 
to give rise to nervous disorders in the child ; and cases have been recorded 
in which severe headache, photophobia, choreic movements, convulsions, 
and even profound coma have ceased on the expulsion of a number of these 
creatures. It is difficult to say what share the worms take in the produc- 
tion of such symptoms. Probably some additional cause is in operation, 
for in rickety children, whose tendency to convulsions and other forms of 
nervous disturbance is one of the most characteristic consequences of that 
phase of general malnutrition, I have not noticed that the presence of the 
long round-worm is especially liable to be accompanied by eclamptic seiz- 
ures. Probably, in most cases where nervous symptoms are associated with 
intestinal worms, the nervous disturbance is quite independent of any irri- 
tation produced by the worms in the bowels. It is common enough for 
children who are suffering from undoubted disease of the nervous centres 



710 DISEASE IN CHILDREN. 

to be infested with lumbrici. Thus, in cases of tubercular meningitis, one 
or more long worms are often expelled by the action of aperients ; but it 
is needless to say that in such a case no amelioration in the symptoms fol- 
lows the expulsion of the parasites. So, also, children under my care suf- 
fering from chorea have passed lumbrici, but I cannot call to mind a single 
case where any improvement in the disease has directly followed the ap- 
pearance of the worm in the stools. 

If, however, the nervous symptoms supposed to be produced by lumbrici 
must be looked upon as somewhat problematical, there are other phenom- 
ena which can be referred with much greater certainty to the irritation set 
up by the entozoa. Severe abdominal pains of a colicky character are not 
uncommon in children who suffer from these creatures ; and looseness 
of the bowels, occurring chiefly at night, is occasionally produced by this 
agency. • I have seen several cases of this kind where a diarrhoea, after per- 
sisting for months, ceased immediately that the worm was got rid of. 

A little boy, aged four years and a half, was said to have been troubled 
for three months with persistent looseness of the bowels. The purging 
was never very severe, but was always worse at night. The motions were 
said to be very slimy, and after a dose of oil, usually contained thread- 
worms. The child often complained of colicky pain and tenesmus. He had 
been slowly wasting from the time the purging first began. The occurrence 
of nocturnal looseness of the bowels, combined with the appearance of the 
tongue, which was very flabby, slimy, and drab-coloured, with large fungi- 
form papillae at the sides of the dorsum, made me suspect the presence of a 
long-worm. I ordered a powder containing one grain and a half of san- 
tonine and half a grain of calomel to be given every night for three nights, 
and to be followed each morning by a dose of castor-oil. After the first 
powder the child passed a long-worm, and the diarrhoea ceased from that 
time. He then rapidly regained flesh. 

As a rule, lumbrici become active at night, and may pass upwards into 
the stomach, or downwards into the colon and rectum. They have been 
known to issue spontaneously from the mouth of a child during sleep, or to 
appear from the bowel without being discharged in a stool. Their pres- 
ence in the stomach may give rise to nausea and retching. Sometimes they 
pass into the common bile-duct and cause jaundice, by obstructing its chan- 
nel. If jaundice rapidly developes in a child who is known to be troubled 
with this parasite, we should think of the possibility of this rare accident 
having happened. Sudden dyspnoea has been known to arise. In some 
instances, at least, this has been discovered to be due to the actual penetra- 
tion of the worm into the air-passages. Thus, Andral has known death to 
occur from this cause ; and Arronsshon has reported the case of a little 
girl, aged eight years, who, after suffering for two hours from distressing 
d3 T spncea and cough, suddenly, after a violent paroxysm of cough, ejected a 
long- worm and was immediately relieved. In other cases, the difficulty of 
breathing has been attributed to direct pressure upon the larynx and trachea 
by a number of worms in the gullet, or to reflex action, propagated from the 
intestine ; but these explanations are neither of them very satisfactory. It 
has been so much the tendency to attribute every kind of discomfort arising 
in cases where worms are present to the irritation of the parasitic creatures 
in the bowels, that probably sufficient care has not been always taken to ex- 
clude other and less obvious causes of the symptoms. 

Lumbrici are sometimes present in very great quantities. The largest 
number I have known to occur together in one child has been twelve ; but 
they are sometimes much more numerous, and may even amount to several 






INTESTINAL WORMS — DIAGNOSIS — TREATMENT. 711 

hundreds. When thus multiplied, the worms may form bundles, which 
impede the passage of the contents of the bowel, and are said in some cases 
to give rise to the symptoms of obstruction. 

The tape-worm is often found in children and sometimes in infants. 
One child who came under my own observation began to pass the joints 
at the age of fifteen months. Other observers have met with the worm in 
still younger subjects. These, however, are exceptional cases, but in 
older children, of five or six years and upwards, the affection is as common 
as it is in the adult. In these patients, little disturbance appears to be 
excited by the parasites. Pallor and loss of flesh are often complained 
of ; but these symptoms, as in the case of the other species of parasite, ap- 
pear to be due less to the worm than to the mucous derangement of the 
bowel with which its presence is usually associated. Headache and dis- 
colouration of the lower eyelid also often occur, and may be attributed to 
the same catarrhal condition. Often, however, the digestion remains 
good, and the child, except for occasionally passing segments with the 
stools, is to all appearance well. 

Diagnosis. — No symptoms are to be relied upon in the diagnosis of 
intestinal worms. The only sign from which we can draw any positive in- 
ference, is the appearance of the creatures or their eggs in the stools. 
Therefore, if from any cause we suspect their presence in the bowels, we 
should at once adopt appropriate treatment, and order the evacuations to 
be carefully searched for signs of the parasites. A microscopic examina- 
tion of the matters discharged from the bowels will often discover the 
presence of the ova. 

Treatment, — With the exception of the taenia, worms are usually ex- 
pelled readily in young subjects ; but it is less easy to prevent their 
frequent reproduction. In all cases where children continue to be in- 
fested for long periods with the oxyures or lumbrici, the bowels will be 
found to be the seat of a chronic mucous flux. There can be little doubt 
that in such cases the ova lodge in the abundant secretion and find in it a 
congenial medium for development. Therefore, in all such cases, the 
special means adopted for relieving the bowels of their unwelcome tenants 
must be conjoined with other measures for arresting the chronic derange- 
ment of the mucous membrane and restoring the intestinal canal to a 
healthy state. These measures consist in the adoption of a careful diet, 
from which sweets and farinaceous matters are in great part excluded ; 
in the frequent use of mild aperients to clear away mucus accumulated in 
the alimentary canal ; and in the administration of alkaline and other reme- 
dies to check hyper-secretion from the mucous membrane. This subject is 
referred to elsewhere (see page 127). 

Thread-worms are most effectually and easily removed by the use of 
enemata. For this purpose, lime-water, or an infusion of quassia, or a 
solution of common salt (a teaspoonful to four ounces of water), may be 
employed. In using these agents, the bowel should first be cleared out 
by a copious injection of warm water. Afterwards, five or six ounces of 
the special enema should be administered, and be retained for a few min- 
utes by pressing the anus before it is allowed to escape. In obstinate 
cases, santonin (one grain to a child of four years old) should be added 
nightly to a dose of the compound liquorice powder or other mild ape- 
rient ; and five grains of tartarate of iron, with one or two drachms of the 
compound decoction of aloes, diluted with water and sweetened by a few 
drops of spirits of chloroform, may be given two or three times a day. 

Looseness of the bowels in these cases is readily arrested by a dose of 



712 DISEASE IN CHILDEEN. 

castor-oil. The nocturnal itching may be greatly relieved by the appli- 
cation to the fundament of an ointment composed of equal parts of un- 
guentum hydrargyri and lard, as recommended by Dr. E. Liveing ; or 
by the use of a salve made by rubbing up one drachm of finely powdered 
camphor with an ounce of lard. In all these cases, the greatest cleanliness 
must be observed, and after each action of the bowels the parts should be 
well washed with soap and warm water. 

In the case of lumbrici, santonin is especially indicated. The remedy is 
best combined with a dose of calomel. Thus, for a child of five or six years 
old, two grains of the former may be given with half a grain of the sub- 
chloride of mercury every night for two or three nights, and be followed 
each morning by a purgative dose of castor-oil. Employed in this manner, 
the drug rarely fails to bring away the round-worm, if one of these crea- 
tures is hidden in the bowels. Santonin is a remedy which should not be 
given in too large doses. In some children it causes vomiting ; in others 
it produces giddiness, with impairment of vision, so that all objects 
seem tinted with a green or j^ellow colour. Usually, it increases the amount 
of urine and gives a yellow tinge to the secretion. 

For children who, on account of vomiting or other toxic effect of the 
medicine, cannot take santonin without discomfort, some alterative remedy 
must be used. Cowhage (the hairs of the mucuna pruriens) may be pre- 
scribed in doses of thirty to sixty grains, given twice a day in treacle or 
glycerine. Dr. W. Roe speaks highly of the sulphites, especially the bi- 
sulphite of soda, and recommends ten or fifteen grains to be given three 
times a day in water sweetened with spirits of chloroform and flavoured 
with tincture of orange-peel. Neither of these remedies has any laxative 
action. Each should, therefore, be always followed by a purgative dose 
of aloes, senna, castor-oil, or other mild aperient. Oil of turpentine is an- 
other useful vermifuge. It can be given in a morning dose of two drachms 
(for a child of six) combined with an equal quantity of castor-oil. 

It is not advisable, in ordinary cases, to continue the use of anthelmin- 
tics if the first doses have been given without effect. It must not be for- 
gotten that all the symptoms of worms (i.e., of irritation of the bowel) may 
be present although special remedies fail to produce any sign of the 
creatures in the stools. If, therefore, after a few trials, no lumbricus is 
discovered, we should attribute the symptoms to the general intestinal 
derangement, and take the necessary steps to bring the disorder to an 
end. 

The successful treatment of tape-worm in the child is often a matter of 
no little difficulty. Probably the softer mucous membrane in the young 
subject adapts itself more readily to the action of the suckers than is the 
case in the adult, for in my experience it is comparatively rare for the 
head to be discovered in the evacuations. The joints can be readily ex- 
pelled, but the head too often remains behind. In all these cases, great 
care should be taken in the examination of the stools. All the visible 
joints should be first removed. The fsecal matter should then be diluted 
with water and emptied slowly from one vessel into another, with every 
precaution that the liquid excreta is thoroughly searched by the eye as it 
passes over the side of the utensil. The sediment remaining should be 
then again diluted and strained through a fine sieve. By this means, the 
head, if it have passed from the bowel, can scarcely escape notice. 

Various kinds of vermifuge are relied upon in the treatment of these 
parasites. Kousso, kamala, filix mas, turpentine, and a decoction of the 
fresh bark of the pomegranate root have all their advocates. Filix mas, 



INTESTINAL WORMS — TREATMENT. 713 

which is the favourite remedy for the adult, is uncertain in the case of 
children. For young subjects, it is best combined with kamala. A drachm 
of powdered kamala is made into an emulsion with mucilage, and then 
triturated in a mortar with a drachm of fern-oil, adding water slowly to 
make a three-ounce mixture. It is important that the remedy be given 
fasting. The child should be allowed to take nothing but a little water 
after his mid-day dinner. The draught should be given on the following 
morning, divided into two portions, of which the second half must be taken 
at an interval of three hours after the first. Kamala has an aperient action 
of its own. This method of treatment, therefore, seldom requires the 
assistance of a purgative, as is necessary in the case of male fern-oil given 
alone. After the two draughts have been swallowed, the patient should 
still continue his fast until the worm comes away in the stool. I have 
found children bear this method of treatment well, and it is often effectual. 
If the draught excite vomiting, it should be repeated, preceded by a small 
dose (Uj, ij.-iij.) of laudanum to quiet the irritability of the stomach. 

Kousso is preferred by some. The remedy is given in doses of two or 
three drachms divided into two portions, and given at an interval of half 
an hour in milk. The draught should be taken in the early morning, and 
should be followed in an hour after the second dose by a spoonful of castor- 
oil. The principal objection to this method of treatment is the large 
quantity of the drug which it is necessary to swallow in order to produce 
any satisfactory effect. The same objection applies to the decoction of pome- 
granate bark. If these remedies fail, turpentine should alwa} r s be tried. 
This oil may be given in one large dose, or in smaller quantities frequently 
repeated. In the large dose it may be administered as recommended for 
the lumbricus. In smaller quantities, Dr. H. Davies recommends half a 
drachm to be mixed with honey and given in a draught with mucilage and 
water every six hours. Every second morning he orders a powder of 
calomel and the compound scammony powder. 

In all cases where there is much derangement of the bowels, and large 
quantities of mucus are passed in the stools, a rigid diet, from which starchy 
matters and sweets are carefully excluded, should be enforced for at least 
a week before the special treatment is undertaken. This precaution greatly 
increases our chances of success. 



Part 10. 
DISEASES OF THE LIVER, 



CHAPTER I. 

JAUNDICE. 



Jaundice is common in early life. This symptom may be found in children 
as a consequence of the same causes which produce it in the adult. There 
is in addition a special form of jaundice seen in new-born babies which is 
called icterus neonatorum. It will be therefore convenient first to describe 
jaundice as it occurs in the new-born baby, and afterwards the symptom 
as it is met with in older children. 

Icterus neonatorum, or infantile jaundice, must be distinguished from 
the yellowish discolouration of the skin which succeeds in many cases to 
the intense cutaneous congestion of the first few hours or days of life. 
This staining is not dependent upon the secretion of bile, and is not a 
jaundice at all. It does not colour the conjunctiva or the urine, but re- 
sembles the staining of the skin which follows a cutaneous bruise. The 
face of the child who is born after a difficult or tedious labour, is often at 
first deep red, with a tinge of violet ; and the skin over the body is coloured 
with an erythematous redness. At the same time, or soon after, pressure 
upon the surface sufficiently firm to empty the blood-vessels shows a yellow 
tint of the skin. As the redness fades, the yellowness appears to increase, 
and soon remains the sole discolouration. Beginning, as a rule, on the 
second day, it usually persists for about a week, and is commonly over by 
about the tenth day, or a little earlier, although in exceptional cases it may 
last longer. By some writers, the term icterus neonatorum is confined to 
this false jaundice, and the same authors apply the name icterus infantum 
to the true disease. This practice is calculated to give rise to unnecessaiy 
confusion. In the following pages the terms icterus neonatorum and 
icterus infantum will be applied indifferently to indicate a staining of the 
skin by the pigments of the bile. 

Real icterus manifests itself in the child as it does in the adult, by a 
yellow tint of the skin and conjunctivae, light-coloured stools, and often by 
discolouration of the urine. It may be the result of some comparatively 
trifling derangement, and is then readily recovered from ; or may be the 
consequence of a serious malformation or grave organic lesion, and is then 
almost invariably fatal. 



JAUNDICE — ICTERUS NEONATORUM:. 715 

The milder form of jaundice — which may be called the benign variety 
— appears to be predisposed to by difficulty and delay in the process 
of parturition. A first-born child, exposed to serious and prolonged 
pressure before birth, and who, in consequence, is born in a state of semi- 
asphyxia, is often found to become jaundiced. Again, according to Kehrer, 
premature birth, or other cause of weakness in the infant, is apt to be fol- 
lowed by the same result. Exposure to cold and damp, and, according to 
some writers, a vitiated atmosphere, can also produce it. 

Many theories have been advanced to account for the frequency of this 
symptom in the newly born. Virchow attributed it to a duodenal catarrh, 
and plugging of the common duct with mucus ; and in children who have 
been exposed to cold this is no doubt a common cause of the derange- 
ment. Frank thought it was the consequence of an accumulation of me- 
conium. Cohnheim believed it to be due to a sudden increase in the bile 
secretion after birth — an increase too great for the bile-ducts to carry 
away ; but he has advanced no evidence in support of his theory. Many 
writers have referred the symptom to the disturbance in the hepatic circu- 
lation consequent upon the change in the conditions of life incident to 
birth. The circulation is too full, according to Hewitt and Weber, so that 
the distended vessels compress the bile-ducts ; it is too empty, according 
to Frerichs, the circulation through the umbilical vein being suddenly cut 
off, and the tension of the hepatic capillaries diminished, so that the se- 
creted bile makes its way into the blood-vessels. 

There can be no doubt that the sudden transference of the chief sup- 
ply of blood from the umbilical to the portal vein must at first produce 
considerable disturbance in the hepatic circulation. Weber has pointed 
out that if the functions of the umbilical vein are arrested before the es- 
tablishment of respiration, as when a child is born partially asphyxiated, 
great congestion and oedema of the liver are the consequence. Birch- 
Hirschfeld has shown that the vessels in the notch of the liver are sur- 
rounded by a dense layer of connective tissue, and that this areolar sheath 
is continued into the organ along the branches of the portal vein. He 
has noted that in cases of difficult parturition, where the liver is the seat 
of great venous obstruction, this areolar sheath is cedematous. It becomes 
pulpy and gray in colour from infiltration of fluid, and a great accumula- 
tion of round cells takes place into its meshes. This pulpy condition of 
the cellular layer is seen also around the umbilical vein, and may even 
extend into the gall-bladder. It is evident that the swollen tissue must 
compress the bile-ducts, and Birch-Hirschfeld has shown that this is 
actually the case. The bile-ducts are distended, and it is difficult to force 
bile out of the gall-bladder into the duodenum. In these cases he has de- 
tected early signs of jaundice where death has occurred during the first 
day, and reports cases in which life had been further prolonged with a 
gradual increase in the icteric symptoms. In these mild cases, the pres- 
ence of the bile-pigment cannot be always demonstrated in the urine ; 
but, according to this authority, the bile acids can be detected in fatal 
cases in the pericardial fluid. 

When the icterus is a consequence of the condition above described, it 
is seldom very severe. In the mildest cases the conjunctiva? are only 
faintly tinted with yellow ; the appearance of the urine and the motions is 
normal ; and the staining of the skin is only noticed on the face, the front 
of the chest, and the back. The derangement is then only a passing one, 
and the skin resumes its natural colour in three or four days. In a higher 
degree, the yellowness may extend to the belly and upper arms. The con- 



716 DISEASE IN CHILDREN. 

junctivae are yellow ; the urine is high-coloured, and stains the linen ; but 
even in this case, the stools may retain their normal tint, which at this age 
is naturally a golden yellow colour. In this degree, the symptoms gener- 
ally last a week. In other cases, the jaundice is general, and may involve 
even the hands and feet. The urine is then distinctly icteric ; the con- 
junctivae are very yellow ; the tears are tinted with bile, and the stools are 
clay-coloured. In some cases, Seux has noticed an ophthalmia to come on 
a few days after the onset of the jaundice, with a copious and deeply- 
stained purulent secretion. As a rule, the child seems to suffer little in- 
convenience from his derangement. He takes his food well and has no 
pain. Often, on palpation of the belly, the liver will be noticed to be in- 
creased in size, and the lower border may be felt at the level of the um- 
bilicus. It is curious that, although the urine is coloured yellow, the most 
careful examination of the water is unable to detect the presence of bili- 
phsein. MM. Parrot and A. Robin have, however, discovered in the ic- 
teric urine yellow amorphous irregular masses, varying in size from a red 
blood-corpuscle to a vesical epithelium, and differing in chemical tests 
from the colouring matter of the bile. They have also noticed the pres- 
ence of sediments containing uric acid, urate of soda, and oxalate of lime ; 
hyaline, epithelial, and fatty cylinders ; white globules, and cells from the 
urinary passages. 

When death occurs in infants who suffer from this benign form of 
jaundice, the fatal termination is owing usually to other causes. There is 
a variety of the complaint, to which attention has been directed by Seux, 
where the icterus is accompanied by all the symptoms of intestinal catarrh 
— diarrhoea, a quick pulse, and some heat and tenderness of the belly. 
There is, however, rarely vomiting. In the favourable cases the diarrhoea 
ceases before the jaundice disappears. If the looseness of the bowels per- 
sists, it is a dangerous derangement at this early age, and the infant often 
dies. 

Although usually a symptom of comparatively little moment, icterus 
neonatorum may be the indication of very serious disease. The grave form 
of jaundice may be the result of three different conditions. There may be 
a congenital malformation of the gall-ducts ; the ducts may be compressed 
by syphilitic inflammation and growth (the syphilitic peripylephlebitis of 
Schiippel) ; or the icterus may be the consequence of umbilical phlebitis 
and pyaemia. 

Infantile jaundice from atresia of the bile-diicts is fortunately not a 
common disease. Several varieties of malformation have been recorded : 
the gall-duct has been found converted into a fibrous cord ; the common 
duct has been known to be obliterated, or absent, or excessively narrowed ; 
sometimes all the ducts have been wanting ; in other cases, the gall-bladder 
has been rudimentary and the ducts absent. The liver itself is normal in 
appearance, or greatly enlarged ; usually, it is of a deep olive or nearly 
black colour. It has also been noticed to be cirrhotic, and its substance 
has been found to be denser than natural. The microscope shows an 
overgrowth of the areolar tissue, chiefly in the capsule of Glisson ; and 
broad bands of connective tissue surround the dark green islets of liver- 
cells. This incipient cirrhosis appears to be a constant accompaniment of 
obliteration of the bile-ducts, and continues to advance as long as the 
child survives. In animals, ligature of the ducts has been shown by Dr. 
Wickham Legg to lead to marked hepatic cirrhosis and consequent portal 
congestion. 

This rare and distressing form of malformation is sometimes found to 



JAUNDICE — CAUSATION. 717 

affect several children of the same parents. This tendency to appear in 
successive children of the same family was noticed by Cheyne in 1801, 
and has been commented upon by other writers. The jaundice to which 
retention of the secreted bile gives rise may be present at birth, but usually 
is not visible before a week, a fortnight, or even longer. When it first 
appears, the discolouration has a faint yellow tint, but the colour gets 
quickly darker. The conjunctiva) are yellow ; the stools soon become 
colourless and offensive ; and the urine is high-coloured and leaves yellow 
or greenish brown stains on the diaper. At first, nothing abnormal is 
noticed about the belly ; but after a day or two the liver begins to enlarge, 
and may reach a great size in a short time. The spleen may be also felt 
to be larger than natural. There is some swelling of the belly, and ascites 
may be present ; but the abdominal distention is usually due to the in- 
crease in size of the hepatic and splenic viscera, and to flatulent accumula- 
tion resulting from the decomposition of food. Dr. Wickham Legg men- 
tions swelling of the haemorrhoidal veins among the occasional symptoms. 
The child usually takes food well, but wastes quickly. The bowels are 
often costive. The jaundice is not constant in degree. The tint of the 
skin varies, and on some clays the infant is much more deeply stained than 
on others. Before death, in some cases, the abnormal colouring almost 
completely disappears, as very little bile is formed, owing to the destruction 
of the secreting tissue of the liver. The stools do not always lose colour 
very rapidly ; sometimes for days, or even weeks, meconium or coloured 
stools may be evacuated ; but the colour is usually described as a dark 
green, and is due possibly to altered blood. 

A frequent symptom of this congenital defect which demands especial 
attention, is haemorrhage from the navel. This phenomenon is not a con- 
stant symptom, but occurs in the majority of cases, and is of very serious 
augury. The haemorrhage generally begins a few hours or a day or two 
after the fall of the navel-string (most commonly between the fifth and the 
ninth day after birth), and usually occurs first in the night. It is not a 
violent bleeding. Blood oozes gently but continuously from the umbilicus. 
It appears to be capillary, and the colour may be bright red, or dark and 
venous. This form of bleeding may be combined with haemorrhage from 
other parts, such as cutaneous ecchymoses, epistaxis, haematemesis or 
melaena, and bleeding from the mouth. The haemorrhage, combined with 
the interference with digestion due to the absence of bile and impaired 
action of the liver, rapidly exhausts the patient ; and he usually dies with- 
in the week — often in a few hours. Dr. Legg suggests that the umbilical 
haemorrhage is a consequence of the cirrhosis and resulting portal conges- 
tion ; for the blood is hindered in its passage through the liver, and is 
forced to seek some other way of escape. It therefore passes from the left 
portal vein to the ductus venosus, and thence to the umbilicus, where the 
vessels, newly closed, cannot resist the increased pressure, and give way. The 
same mechanism (portal congestion) will explain the frequent coincidence 
of haemorrhage from other parts supplying the portal vein with blood. 

Cases of jaundice conjoined with umbilical haemorrhage are rapidly fatal, 
When this symptom is absent, although the child almost invariably dies, 
life may be preserved for a much longer period. Recorded cases show 
that the infant may live five, six, or seven months, and even then, as in 
Lotze's case, where the child lived into the beginning of the eighth month 
and died of a broncho-pneumonia, may succumb to an accidental compli- 
cation. This malformation is said to be twice as common in boys as it is 
in girls. 



718 DISEASE IN CHILDREN. 

A male " infant, deeply jaundiced, aged three months, was brought to 
the out-patients' room of the East London Children's Hospital and was at 
once admitted by my colleague, Dr. Radcliffe Crocker, into the wards. 
The child was born of healthy parents, none of whose other children had 
been similarly afflicted. He was said to have been a robust, healthy- 
looking infant at birth, and shortly afterwards to have passed two dark 
stools. Since that time, however, his motions had been hard and white, 
like lumps of chalk, and the bowels had acted only once a day. The jaun- 
dice had first appeared when the child was a week old, and had progressively 
increased. The infant had been suckled for a month, and was then fed on 
Swiss milk. He often vomited, not always after taking food, and was 
capricious about his bottle, sometimes refusing to suck. His water had 
always been dark, leaving yellow stains on the diaper. 

When admitted, the child was fairly nourished. His skin was deeply 
jaundiced, and his conjunctivae were yellow. There was a papular eruption 
(strophulus) all over his body. The liver could not be felt at this time on 
account of the child's struggles, but was found a few days afterwards to 
project two fingers' breadths below the ribs. The boy lived a month after 
his admission, wasting gradually, and often crying as if in pain. Then 
aphthae appeared in his mouth, and he sank and died. There were no 
haemorrhages. His jaundice persisted, although it varied curiously in in- 
tensity ; and before his death the tint of the skin was several shades lighter 
than when he entered the hospital. The liver remained about the same 
size and felt firm and smooth. The spleen was not enlarged. After death 
the liver was found of a dark olive colour, and its consistence seemed to 
be increased. The gall-bladder was rudimentary, and the hepatic and 
common ducts were absent. 

"When syphilitic inflammation of the liver gives rise to jaundice, the or- 
gan is enlarged and deeply coloured of a brownish yellow tint, and shows 
under the microscope a great proliferation of young cells in the capsule of 
Glisson, and in the interlobular spaces. In a case recorded by M. D'Espine, 
of Geneva, the same proliferation was noted round the hepatic cells in the 
interior of the lobules. Moreover, the small bile-ducts were thickened 
and filled with epithelial cells. There was no obstruction in the larger 
ducts, and the gall-bladder contained thick and dark-coloured bile. The 
spleen was greatly enlarged and very firm. 

In this case the jaundice was severe and appeared at birth. On the 
ninth day bleeding occurred from the umbilicus, from the bowels, and into 
the skin ; the belly swelled ; the liver and spleen were notably enlarged ; 
the temperature became subnormal ; the child wasted rapidly, and died on 
the twenty-third day in convulsions. 

Jaundice from umbilical phlebitis has been called by Schiiller "icterus 
malignus." This variety appears to be dependent upon an infective pro- 
cess. The poisonous matter is probably the same as that which causes 
puerperal fever in the mother, and may be conveyed by bacteria, for two 
forms of micro-organisms have been found in the blood of infants so 
affected, the one spherical and the other rod-shaped. Whether these 
two different forms imply two different kinds of infection is not known, 
but Birch-Hirschfeld asserts that the rod-shaped bacteria are especially 
observed in cases where the general infection is severe and the disease 
violent from the first, with a strong tendency to haemorrhage. These 
cases are accompanied by inflammation of the umbilical artery, with or 
without phlebitis of the umbilical vein. In sixty cases collected by this 
observer, umbilical arteritis was found in thirty- two, umbilical phlebitis 



JAUNDICE — DIAGNOSIS. 719 

in eleven, and inflammation of both vessels in three. An examination of 
the liver reveals profound degeneration. These changes seem to indicate 
that the infection must reach the liver by the umbilical vein. They may, 
however, be found in cases where the artery alone is notably diseased ; 
but there are reasons why the morbid appearances should be more con- 
spicuous in the umbilical artery. After birth, the remnant of the umbilical 
vein is alternately emptied and filled again on account of the varying 
pressure on the hepatic vessels induced by the action of the heart and 
lungs. This constant flux and reflux in the vein tends to promote infec- 
tion of the system, but is unfavourable to the local development of the 
morbid process. It is found in these cases that the intensity of the jaun- 
dice bears no relation to the severity of the vascular inflammation, but that 
it is in direct proportion to the degree to which the pathological changes 
have advanced in the liver. It is probably, therefore, the consequence of 
the swelling of the connective tissue surrounding the portal vein and its 
branches in the liver, which compresses the bile-ducts. 

In these cases, the jaundice comes on a few days after birth, and by the 
end of the week is well marked. The urine is intensely yellow ; but 
the stools may be of normal tint, although usually costive. The onset of 
the jaundice is accompanied or quickly followed by fever, which soon be- 
comes high. There is often vomiting of yellow or greenish matter. The 
child looks excessively ill. His face is livid, with pinched, haggard features, 
and he refuses the bottle or the breast. His tongue is dry ; his hands 
and feet are purple ; his abdomen swells and is tender ; fluctuation, more 
or less distinct, is noticed ; and blood or blood-stained pus oozes from the 
navel. Sometimes the spleen enlarges, and petechias are noticed on the 
skin. Death may be preceded by convulsions and coma. 

When jaundice occurs after the age of infancy, it is due to the same 
causes which give rise to the symptom in the adult. Of these, no doubt, 
duodenal catarrh extending into the bile-ducts is, of all others, the most 
frequent. On this account, the symptom is usually a trifling one, and is 
quickly recovered from. It is accompanied by some temporary enlarge- 
ment of the liver, which can be felt to project several fingers' breadths be- 
low the ribs ; but except for some delicacy of digestion, little discomfort is 
experienced. In exceptional cases, the derangement may be the conse- 
quence of plugging of the common duct with inspissated bile, and thi3 
accident has been noticed in an infant of three months old. Again, a 
lumbricus has been known to penetrate into the common duct and produce 
such impediment to the flow of bile as to give rise to jaundice. Icterus 
may be also due to acute yellow atrophy of the liver ; but this is fortunately 
a very rare disease in childhood. Of other causes, atrophic cirrhosis of the 
liver, phosphorus poisoning, and miasmatic influences have been recorded 
as producing jaundice in early life. 

Diagnosis. — In examining a new-born infant for signs of jaundice, it is 
often necessary to force the blood out of the skin by firm pressure with 
the finger before the natural tint of the integument can be observed. In 
inspecting the eyes for yellow staining it is advisable to use no force in 
attempting to open the lids with the finger, but rather to wait until the 
child opens his eyes spontaneously. A baby, when the eyelids are touched, 
squeezes them together instinctively. In such a case our utmost efforts 
will often succeed only in exposing the palpebral mucous membrane, and 
this will quite conceal the globe of the eye from view. 

The diagnosis between false jaundice and true icterus neonatorum, if 
the latter be of the benign variety and little pronounced, is very difficult — 



720 DISEASE IN CHILDREN. 

often quite impossible. In neither case is the conjunctiva stained or the 
urine yellow. The colour will sometimes help us, for the tint of the jaun- 
diced skin is often more distinctly yellow than the brownish stain left 
after severe cutaneous congestion. In all cases where the conjunctivae and 
urine are tinted, however slightly, we may conclude that the case is one of 
true jaundice. The condition of the stools is of less moment, for jaundice 
may be present without the motions being clay-coloured. 

In cases where the jaundice persists and becomes deeper and deeper, 
we have every reason to suspect the existence of some congenital mal- 
formation, especially if a previous child of the same parents has died 
shortly after birth with symptoms of icterus neonatorum. If the liver and 
spleen become enlarged, the temperature remaining low, this suspicion 
becomes almost a certainty ; and the occurrence of bleeding from the navel 
is, in such a case, practically conclusive. The partial disappearance of the 
jaundice is no proof that our apprehensions are unfounded, for the yellow 
tint of the skin may become distinctly lighter, or even quite disappear be- 
fore the end. 

The pycemic form of jaundice is readily detected. The general appear- 
ance of the child, the high temperature, the dry tongue, the swelling and 
tenderness of the belly, the discharge of blood and pus from the umbilicus, 
and the early death, sufficiently indicate the nature of the disease. 

If the jaundice is accompanied by signs of inherited syphilis, or if, 
without these, we can discover a history of syphilis in the father, or of 
previous miscarriages on the part of the mother, the probability of a 
syphilitic origin to the jaundice must be taken into consideration. 

Prognosis. — So long as the jaundice is accompanied by no signs of 
discomfort, little anxiety need be excited by the symptom ; but if diarrhoea 
or vomiting occur, the injurious effect of exhausting discharges upon a 
newly born infant must not be overlooked. Little information is to be 
gained by inspection of the stools, for in cases of serious malformation 
they may remain normal in appearance for a considerable time. If, in any 
case, the motions become clay-coloured, and the staining of the skin and 
urine shows no sign of subsiding, there is cause for apprehension. A 
slight enlargement of the liver (i.e., a projection of one finger's breadth 
below the ribs) is immaterial ; but if the organ continue to increase in size, 
and if the spleen also begin to swell, the infant's condition is becoming a 
serious one. It must not be forgotten in these cases to examine the anus ; 
for the appearance of any swelling of the hsemorrhoidal veins, as indicating 
great obstruction to the portal circulation, is an unfavourable symptom of 
no little importance. 

If we are satisfied that the case is one of congenital deficiency or mal- 
formation, we can have little hope of a favourable issue, although life may 
be prolonged for several months. The appearance of umbilical haemorrhage 
is a very fatal sign, and is usually followed by rapid sinking of the patient. 

If the jaundice is due to syphilitic disease, it is hardly likely to end 
otherwise than unfavourably ; and in cases of umbilical phlebitis and 
pyaemia, we can hold out no hope of recovery. 

In older children, icterus, unless it be due to phosphorus poisoning or 
some profound hepatic lesion, is in most cases a mild derangement which 
soon passes away. 

Treatment. — Ordinary benign jaundice in the new-born baby requires 
little treatment. Emetics, although strongly recommended by some writers, 
are in most cases useless, if not injurious. A gentle purge, such as castor- 
oil, followed by two or three grains of bicarbonate of soda with a quarter 



JAUNDICE— TREATMENT. 721 

of a drop of tincture of nux vomica, given three times a day, will soon 
restore the child's tissues to their natural colour. I now invariably give nux 
vomica with an alkali in these cases, and believe that in catarrhal jaundice 
at all ages the former drug has a distinct influence in aiding the child's 
recovery. If purgatives are prescribed, the aperients used should be those 
which, like castor-oil or aloes, act low down in the alimentary canal. Senna 
and other drugs which influence the duodenum and upper part of the 
bowels may increase the irritation of this part of the intestine, and are 
unsuitable to cases of jaundice — at any rate to those cases where there is 
reason to suspect the existence of duodenal catarrh. Mercurials, too, 
should be given with judgment. It is not advisable to continue acting 
upon the liver by repeated doses of mercury. One dose of gray powder 
or of calomel may be allowed, but the remedy need not be afterwards re- 
peated. With regard to diet : — The infant may still continue to take the 
breast. If he be bottle-fed, no alteration need be made in his food unless 
vomiting occur with signs of acid fermentation. If these symptoms of 
gastric catarrh are noted, the diet must be regulated according to the rules 
laid down in the chapter on Infantile Atrophy. 

If the jaundice be due to malformation, no treatment can be expected 
to be of service ; but if haemorrhage occur from the navel, attempts should 
be made to arrest a symptom which experience has proved to be so speed- 
ily fatal. The perchloride of iron may be used locally, followed by a com- 
press ; but in most cases, the surgeon has to fall back upon the operation 
known as the " ligature en masse." The child should be laid upon his back, 
and two hare-lip pins must be passed through the integuments at the root 
of the navel, carefully avoiding the peritoneum. A ligature is then twisted 
tightly round the needles in the form of a figure of eight. 

If syphilis be present in the child, treatment for this constitutional con- 
dition should be adopted without loss of time. In cases of pyseniic jaun- 
dice, attempts must be made to relieve the distressing symptoms. Warmth 
should be applied to the belly ; and if there is great tenderness about the 
umbilicus, extract of belladonna diluted with an equal quantity of glycerine, 
can be applied to the skin round the navel. Stimulants must be given as 
required. 

46 



CHAPTER II. 

CONGESTION OF THE LIVER. 

Congestion of the liver, although a common derangement in the child, 
is yet often suspected when not actually present. Many symptoms attrib- 
uted to a "torpid," "inactive," or congested liver, and treated with gray 
powder, are really due to a disordered state of the stomach dependent upon 
an improper dietary, and may be readily relieved by the exercise of a little 
judgment in the child's food and general management. A liver morbidly 
congested gives rise to a very definite group of symptoms, as will be after- 
wards described. 

Causation. — The amount of blood circulating in the liver may vary con- 
siderably within normal limits. During digestion it is increased for the 
time ; and if the child be habitually overfed, or be frequently indulged 
with highly spiced and stimulating food, the hyperemia lasts longer and is 
more intense than if he eat more moderately or of a plainer diet. Want of 
exercise and too close confinement to the house will increase the injurious 
effects of this unwholesome regimen. The other principal causes of mor- 
bid congestion of the liver are : — Any cause which interferes with the return 
of blood from the liver. The commonest of these is disease of the heart, 
interfering with the return of blood from the lungs. The pulmonary cir- 
culation suffers primarily ; and secondarily, the impediment spreads to the 
vena cava and the portal vein. Congestion of the liver is also a consequence 
of the ague poison, for malarial fever is as common a cause of hepatic con- 
gestion as it is of splenic enlargement, and a swollen hypersemic liver is a 
familiar symptom in tropical climates. Again, chilling of the surface is one 
of the most frequent agents in the production of liver congestion, and en- 
largement of the organ from this cause is a usual accompaniment of ca- 
tarrhal jaundice. 

Morbid Anatomy.— A. congested liver is enlarged in all directions, and is 
very thick ; its resistance is increased, and the peritoneal coat is tense and 
shining. "When cut into, the organ bleeds freely, and the section shows a 
spotted or " nutmeg " surface from dilatation of the intra-lobular veins. Of- 
ten, the colour of the parenchyma surrounding the central vein of the lobule 
is yellowish from interference with the escape of bile from the ducts ; for 
jaundice is not unfrequently associated with this hepatic congestion. 

If the hypersemia of the organ is a chronic condition, further changes 
take place after a time. The enlargement of the intra-lobular hepatic veins 
induces atrophy of the liver-cells in their immediate neighbourhood. Sur- 
rounding these cells are others which are stained deeply with bile, and at 
the circumference of the lobule the cells are often filled with oil. The 
atrophied cells ma} r completely disappear ; and eventually a new formation 
of fibroid tissue takes place in connection with the inter-lobular vessels. 
The fibroid growth shrinks, and a condition akin to cirrhosis is set up ; the 
organ becoming granular on the surface and the capsule thickened. 



CONGESTION OF THE LIVEK — SYMPTOMS — DIAGNOSIS. 723 

Symptoms. — If the liver be much congested, we generally find that there 
is some pain in the right hypochondriac region ; that it is tender when 
pressed ; and that coughing or a deep inspiration is distressing. The child 
is often unwilling to lie on either side — on the right because of the direct 
pressure ; on the left because of the weight of the congested organ causing 
an uneasy dragging sensation. On palpation of the belly, the edge of the 
liver is felt several fingers' breadths below the ribs, and on percussion we 
generally find that the upper limit of dulness, instead of beginning in the 
fourth interspace, begins in the third or on the third rib. Sometimes, es- 
pecially if there is jaundice, the distended gall-bladder can be felt as a pear- 
shaped tumour below the inferior edge of the liver. 

Dyspeptic symptoms from hyperemia of the gastric vessels generally ac- 
company a congested liver. The tongue is furred ; there may be headache ; 
nausea may be complained of ; the bowels may be relaxed, and the stools 
light-coloured and offensive. The urine is dark, and may throw down a 
copious deposit of lithates. The skin is often sallow ; and if the conges- 
tion be accompanied by duodenal catarrh, there will probably be jaundice. 

If the congestion is due to cardiac disease the child is harassed with 
dyspnoea and cough from interference with the pulmonary circulation ; his 
digestion is deranged, and there is often, in addition, oedema of the lower 
limbs, with albuminuria. 

A congested liver is, as has been said, frequent in cases of ague. 
Often, until this condition is remedied, quinine has but little influence over 
the attacks. This subject is discussed elsewhere (see Ague). 

Diagnosis.— A. congested liver is increased in size, and pressure upon 
it produces some uneasiness. Mere light-coloured offensive stools are not 
in themselves a sign of hepatic hypersemia. It is common for a child who 
is being fed upon large quantities of farinaceous food, or who, owing to a 
catarrhal condition of his stomach and bowels, is for the time incapable of 
digesting a milk diet, to evacuate more or less semi-solid pasty or putty- 
like matter from the bowels. But the stools in such a case consist of un- 
digested food, and are not indicative of arrested biliary secretion. If such 
a condition be treated, as it often is, by repeated doses of gray powder or 
other form of mercurial, the aperient action of the medicine produces on 
each occasion a dark biliary stool, but the effect of the drug having passed 
off, the evacuations continue to be as pasty as they were before. This con- 
dition, as is elsewhere explained, must be treated, not by cholagogues, but by 
measures which rectify the gastric and intestinal derangement (see p. 640). 

To justify the diagnosis of hepatic congestion we must require enlarge- 
ment and tenderness of the liver and a sallow complexion, as well as diges- 
tive disturbance and light-coloured stools. We must not, however, con- 
clude too hastily that the size of the liver is abnormal. The organ is apt 
to vary in size in young subjects from natural causes, and in some children 
whose chests are exceptionally short may project for a finger's breadth or 
so below the ribs without being congested or otherwise diseased. Be- 
sides, it is important not to mistake a liver merely displaced for a liver 
morbidly enlarged. The organ may be pushed down by fluid accumulation 
in the pleura, or by emphysema of the lung ; and I have known an exten- 
sive pericardial effusion to produce the same effect. In rickety children 
with deeply grooved chests, the liver and spleen, although not enlarged, 
may be felt more distinctly than natural, being forced downwards some- 
what from their original position. It is therefore important to ascertain 
by percussion the upper limits of the liver dulness as well as the exact 
Level of the inferior margin. Again, a liver, although enlarged, may lie 



724 DISEASE IN CHILDREN. 

completely under cover of the ribs, and its abnormal condition may thus 
escape notice. It may be pushed upwards by fluid accumulation and 
growth in the belly ; or may be placed higher than it otherwise would be 
through the shrinking in the chest of a collapsed or indurated lung. 
Therefore, in an examination of the organ, we must remember these sources 
of error, and ascertain all its limits before coming to a conclusion. 

A good example of a congested liver is seen in the following case : A 
little boy, aged three years, of healthy parentage, was brought to the East 
London Children's Hospital with the history that for five weeks he had 
been noticed to be languid and chilly, with little appetite and with some 
swelling and tenderness of his belly. The bowels had acted two or three 
times a day, the motions being light-coloured, thin, and scanty. The child 
was restless and fretful, sleeping uneasily, and often starting and twitch- 
ing in his sleep. 

The boy was the subject of moderate rickets. .His ribs were beaded, 
the ends of his long bones large, and his chest was flattened laterally. He 
had cut all his teeth and his fontanelle was closed. The skin was harsh 
and dry, and was tinted all over the body of an earthy yellow colour. 
The belly was large, and the lower edge of the liver reached to nearly the 
level of the umbilicus. Its substance was natural, without any increase in 
firmness. Its edge was not thickened. The spleen could not be felt. 

The patient was treated with mercurial purges followed by salines, and 
an alkali with bitter ^fusion was given to him three times a day. In a 
fortnight after this treatment had been begun, the liver had become much 
reduced in size. Its upper border was at the fifth rib, and its lower bor- 
der could be felt two fingers' breadths below the ribs. It was evidently 
pushed downwards by the rickety deformity of the chest, and was no 
doubt now of natural size. As the liver became smaller, the child's ap- 
petite improved ; his skin lost its earthy yellow tint, and the colour and con- 
sistence of the stools became natural. 

In this case, all the symptoms pointed to congestion of the liver ; and 
palpation of the belly detected enlargement of the organ without any al- 
teration in its consistence. 

In warm climates, it is important to exclude hepatitis. In suppurative 
inflammation of the liver, the pain and tenderness are greater than if the 
liver be merely congested ; the general disturbance, although considering 
the serious nature of the disease proportionately slight, is greater ; the 
child looks ill, which is not the case in uncomplicated congestion, and 
there is fever. 

Prognosis. — Congestion of the liver is in itself a trifling ailment. Any 
danger connected with the case is dependent upon the general condition 
of the child, or the existence of serious disease of a vital organ. 

Treatment. — If the congestion is dependent upon overfeeding and in- 
sufficient exercise, we should be careful to regulate the diet, and allow only 
food which is digestible and unstimulating as well as moderate in quantity. 
The child should be restricted for a day or two to bread and milk with 
mutton-broth or a little boiled fish for his dinner. His belly should be 
protected by a flannel band, and the action of the skin should be promoted 
by a warm bath before going to bed. The medicinal treatment should 
begin with a few grains of gray powder combined with half a grain of 
powdered ipecacuanha and two to five of jalapine. This should be given 
at bedtime, and in the morning the child may take a dose of liquid 
magnesia or other saline aperient. Eemedies which act upon the skin 
and kidneys are useful in these cases. We may give two or three times a 



CONGESTION OF THE LIVER — TREATMENT. 725 

day a mixture composed of solution of acetate of ammonia, sweet spirits of 
nitre, and a few grains of the bicarbonate of soda or potash. Chloride of 
ammonium (gr. iij. to gr. vj.) is also recommended. It may be made 
palatable by extract of liquorice, chloric ether, and glycerine. 

The same treatment is useful if the hepatic congestion can be attributed 
to a chill. In these cases, especially if there is jaundice, we should be 
careful not to employ senna and other purgative drugs which act principally 
upon the upper part of the intestinal canal, in order not to increase the 
irritation of the duodenum ; but should keep the bowels regular by aloes 
or the saline aperients. 

If the congestion of the liver occur as a consequence of heart disease, 
it will be relieved by measures directed to strengthen the cardiac action 
and lessen the general hyperemia from which the patient is suffering. If 
it arise in the course of an attack of malarial fever, it must be reduced as 
rapidly as possible by saline and mercurial purges (see Ague). 

Children who are habitually indulged and injudiciously fed, especially 
if they are accustomed to warm stuffy rooms, may suffer from frequent 
attacks of hepatic congestion, and their livers may seem to be permanently 
enlarged. In such cases, it is useful to send them to a watering-place 
where they can drink regularly of some natural saline aperient, and take 
daily and sufficient exercise in the open air. After a short course of the 
waters, iron and quinine can be given with benefit. 



CHAPTER III. 

CIRRHOSIS OF THE LIVER. 

Cierhosis of the liver, although not one of the more common diseases in 
the child, cannot be said to be very rare. In some children, even at a 
very early age, there appears to be a peculiar tendency to the formation 
and proliferation of fibroid tissue. Sometimes the fibroid overgrowth is a 
general one ; sometimes it is more local, and is limited to particular organs 
— the lungs, the liver, or the kidneys. Fibroid induration of the lungs 
occurring as a result of catarrhal pneumonia and pleurisy, is a sufficiently 
familiar experience ; but a similar pathological change in other internal 
organs is much less frequently met with. 

Causation. — The causes of hepatic cirrhosis in early life are obscure. 
Intemperance in alcohol, to which the disease in the adult is usually attrib- 
uted, is of course exceptional in the case of a child. It is possible that, 
as some writers are disposed to believe, this vice may be one of the sins of 
the fathers which are visited upon their offspring, and that cirrhosis in the 
child may be due to intemperance in the parent ; but this, at present, at 
any rate, is no more than hypothesis. Congenital deficiency of the bile- 
ducts is often — always, according to Dr. Wickham Legg — accompanied by 
an early stage of hepatic cirrhosis. Syphilis may sometimes produce it ; 
and MM. Cornil and Eanvier have described an interstitial hepatitis as ac- 
companying cases of general tuberculosis. Hepatic cirrhosis has been seen 
at a very early age. Weber has found the atrophic form in a new-born 
infant ; and in cases of malformation of the bile-ducts, it is always an early 
change, as death usually takes place in the course of a few months. The 
hypertrophic form is sometimes, also, met with in very young children. 
Wettergren has seen it in a boy of five ; and Dr. S. West has reported a 
case in a boy of six. It is curious that in each of these instances the child 
had been in the habit of drinking largely of coffee. 

Morbid Anatomy. — Cirrhosis of the liver may be atrophic or hypertrophic, 
and these two conditions have very distinct pathological characters. 

In atrophic cirrhosis (the hobnailed liver, cirrhosis of Laennec) there is 
abnormal development of new fibroid tissue which permeates the organ, fol- 
lowing the branches of the portal vein. The new development appears to 
originate in a chronic inflammatory condition of these vessels. It produces 
great thickening of the capsule of Glisson, the prolongation of which en- 
velopes the portal branches, and extending from it into the interlobular 
spaces, forms meshes which embrace portions of the hepatic substance. 
These portions vary in size, but all comprise several lobules. The process 
consists in a rapid proliferation of embryonic cells which undergo conver- 
sion into cicatricial fibroid tissue. After a time, contraction takes place in 
the new material, and the liver becomes small and shrunken, with an ir- 
regular granular surface and a dense substance. Its enveloping capsule is 



CIRRHOSIS OF THE LIVER — MORBID ANATOMY — SYMPTOMS. 727 

muck thickened. On section, the surface is of a dirty yellow colour, and 
is seen to be divided into irregular meshes by the fibrous network. 

The contraction of the dense interstitial tissue compresses the lobules 
so that the liver-cells become flattened and atrophied, and causes great ob- 
struction to the portal circulation. Consequently, the whole portal system 
is congested. Its blood, unable freely to escape, has to find a new channel ; 
and a collateral circulation becomes gradually established by enlargement 
of the principal veins in the suspensory ligament passing to the umbilicus. 

The nutrition of the liver, and the formation of bile, are kept up by the de- 
velopment of new vessels, which permeate the new fibrous tissue and convey 
blood from the hepatic artery to the intra-lobular vessels. The smaller bil- 
iary ducts are but little affected by the changes which take place, so that 
there is seldom retention of bile or jaundice. In this form of cirrhosis, the 
organ is somewhat enlarged in the early stage, but afterwards becomes very 
small and contracted. 

In hypertrophic cirrhosis, the liver is usually larger than in health, and 
may be increased to twice its natural size. It is smooth on the surface, 
with a normal thin edge, and on section, its substance is orange yellow or 
green in colour. The fibroid overgrowth in this case follows the ramifica- 
tions of the biliary ducts. It begins round the intralobular branches of 
the ducts, and envelopes each lobule so as to insulate it from its neighbour. 
It forms a less regular meshwork than the preceding variety, and is a more 
diffused growth, which in some parts is thick and dense so as completely to 
destroy the hepatic tissue ; in others, is comparatively scanty and ill-de- 
veloped. The affected ducts become largely dilated and their epithelium is 
increased. New ducts are also developed, and can be seen by the micro- 
scope embedded in the new fibroid tissue. In this form of the disease, the 
obstruction is chiefly in the ducts, so that there is no necessary interference 
with the portal circulation. 

These two forms of the disease, from their anatomical origin, have been 
called portal and biliary cirrhosis. 

There is a third form which is very rarely met with. It has only been 
noticed in some cases of inherited syphilis in the infant. The disease is 
here primarily intralobular, and developes within the lobules round the 
individual liver-cells. This form, as it is only discovered after the death of 
the child, and probably gives rise to no symptoms, need not be further re- 
ferred to. 

Symptoms. — On account of the different pathological conditions in the 
atrophic and hypertrophic varieties of hepatic cirrhosis, the symptoms in 
the two forms are not precisely similar. In both we find signs of interfer- 
ence with general nutrition, but as the morbid change affects chiefly the por- 
tal circulation in the one variety, and the biliary conduits in the other, the 
later phenomena differ greatly in the two cases, and are usually character- 
istic. 

In atrophic cirrhosis, the early symptoms are merely those of indiges- 
tion, flatulence, and general discomfort. The child is often peevish aDd fret- 
ful ; he is restless, sleeping badly at night ; and his complexion is sallow or 
pasty-looking, with dark discolouration of the lower eyelids. He is noticed 
early to be flabby, and sometimes is evidently losing flesh. His bowels are 
often costive. These symptoms may continue for a long time without 
change. The urine is apt to be thick with lithates, and may contain crys- 
tals of uric acid, or even a deposit of uric acid sand. It is often very acid. 

Sooner or later, more distinctive symptoms begin to be noticed, and in 
hospital patients it may be only from this point that the child's illness is 



728 DISEASE IN CHILDBED. 

dated by the parent. The occurrence of ascites, with swelling of the belly, 
is usually the first symptom complained of, and there may be some wander- 
ing pains in the side. When the child comes under observation, we usually 
find dilatation of the superficial abdominal veins, distinct fluctuation in the 
abdomen, and often a slight enlargement of the liver and spleen. There is 
little or no jaundice, but the skin after a time begins to have an earthy tint, 
and feels dry and rough to the finger. Sometimes there is a little oedema 
of the feet. The ascites is found to vary greatly in amount, and the general 
condition of the child is subject to rapid variation. On some days he seems 
much better than on others, and may be then lively, playful, and although 
easily tired, even active if allowed to be on his feet. As the disease pro- 
gresses, the liver shrinks and ceases to be felt, but the spleen in most cases 
continues to increase in size. If the ascites is great, it is often difficult to 
feel the spleen even when the child is laid on his right side. In such cases, 
it may be often readily detected by placing the patient on his hands and 
knees. The weight of the organ then brings it well forward within the 
reach of the fingers. Haemorrhages occur in the child from the gastro- 
intestinal mucous membrane as they do in the adult ; and the motions may 
be dark and sooty from blood, or pure blood may be passed by stool. Vomit- 
ing of blood is also sometimes met with. In many cases, we find a tendency 
to haemorrhage from other parts. The nose and gums may bleed, and 
ecchymotic spots may be noticed on the skin. As the symptoms increase, 
the digestive derangements become more and more disturbed. The child 
is much troubled with weight in the epigastrium, and abdominal pains. 
He often feels sick ; sometimes he vomits ; his tongue is furred ; he is thirsty, 
and his appetite is capricious or is lost. He gets thinner and thinner ; 
the dingy hue of his skin becomes more and more marked ; even at this 
early age, hemorrhoidal swellings may be noticed, and the distention of the 
superficial abdominal veins is increased. 

When the disease reaches this period, life is very near its close. Often 
there is general dropsy, but the child may sink and die without the aj> 
pearance of any fresh symptoms ; or diarrhoea may come on and prove rapidly 
fatal. In other cases he dies from haemorrhage, or from an intercurrent 
inflammation, such as pleurisy or pneumonia. Unless a complication be 
present, there is never any fever. The progress of atrophic cirrhosis is 
slow, especially in the earlier stages. If haemorrhage occurs, it is usually a 
sign that the illness is approaching its termination. 

In the hypertrophic variety of cirrhosis, the initial symptoms of gastro- 
intestinal derangement, pallor, and wasting, are the same as in the other 
form ; but the after-course of the disease varies from the previous type. 
While in atrophic cirrhosis the more characteristic phenomena are de- 
pendent upon the obstruction to the portal circulation, in the hypertrophic 
variety the symptoms are due to interference with the biliary system of 
ducts. Jaundice, rare and faint if it occur at all in the previous form, is 
here an early and characteristic symptom. The skin, conjunctivae, and 
urine soon become deeply tinged with orange yellow, and the motions are 
light-coloured or chalky. The liver is generally enlarged, and the spleen 
in most cases can be felt of unusual size ; but there is little dilatation of the 
superficial veins of the abdomen. Pain may be complained of over the 
liver. The bowels are relaxed or inclined to be costive. There is no as- 
cites. 

As the disease progresses, the jaundice increases in intensity, and the 
symptoms generally undergo temporary exacerbation. At these times, rapid 
enlargement of the liver is noticed ; there is slight fever ; the child is peevish 



CIRRHOSIS OF THE LIVER — SYMPTOMS — DIAGNOSIS. 729 

and fretful, crying with pain in Ms side, and his condition appears to be 
changing quickly for the worse. 

The illness often closes with all the signs of malignant jaundice, due, 
probably, to acute degeneration of the hepatic cells. The pulse undergoes 
curious alterations in frequency, sometimes beating rapidly, at others 
slackening to 60 or 70. The tongue gets dry and brown, and sordes 
appear on the teeth. The child refuses food, and seems to care only to be 
left alone. He sleeps much, and is drowsy and stupid when awake. 
Petechias are often seen on the skin ; the gums may bleed, and blood may 
be vomited from the stomach. The drowsiness soon deepens into stupor ; 
and the child lies with his eyes closed, insensible to all that passes, often 
grinding his teeth continuously. There is no pyrexia. The wasting is 
now rapid, and the patient sinks and dies without recovering conscious- 
ness. Sometimes death is preceded by convulsions. 

Although these two types of the disease differ in the distribution of 
the fibroid overgrowth in the liver, they may be both present together. 
In such cases the liver is enlarged, and we find jaundice combined with 
ascites and swelling of the abdominal veins. The hepatic disease may be 
the only lesion of the kind present, or may be accompanied by similar 
changes in the lungs, the kidneys, or the spleen. 

Diagnosis. — So many cases are now on record of hepatic cirrhosis oc- 
curring in children that the diagnosis should be no more difficult in them 
than it is in the adult. It is probable that many cases of ascites, the origin 
of which is obscure, may be attributed correctly to this condition of the 
liver. If in such a case fibroid disease of the lungs can be detected, it ren- 
ders a similar condition of the liver highly probable. A swollen fluc- 
tuating abdomen, an enlarged spleen, dilatation of the superficial veins of 
the belly, piles, a diy, faded, earthy skin — these symptoms occurring in a 
child who is not feverish, but who has a history of previous failure of 
health and of wasting, should make us strongly suspect the existence of 
the atrophic form of cirrhosis. The absence of fever is an important ele- 
ment in this group of symptoms. If haemorrhages occur from the stomach 
and bowels, or elsewhere, the temperature still remaining normal, the 
symptom is strongly confirmatory of our opinion. The chief difficulty in 
these cases arises from the occurrence of a febrile complication ; but this 
is a source of perplexity common to most forms of chronic disease in the 
child. If there be fever when the child first comes under observation, it 
is advisable to withhold a positive opinion until time has been allowed for 
the pyrexia to subside. 

In the case of hypertrophic cirrhosis, the occurrence of gradually in- 
creasing jaundice, with an enlarged liver and pains in the side, but without 
ascites, piles, or dilated parietal veins of the belly, the child being the 
subject of chronic digestive derangement and wasting, is a characteristic 
grouping of symptoms. If the illness end with convulsions, coma, a ty- 
phoid condition, and the symptoms of malignant jaundice, the case maybe 
mistaken for one of acute yellow atrophy, especially if, as may happen, 
the liver is not notably enlarged. The latter is, however, an acute disease, 
and comes on very abruptly, with few or no premonitory symptoms ; while 
hypertrophic cirrhosis is essentially a chronic illness, with a long history 
of failing health. Moreover, acute yellow atrophy is so rare in the child 
that it may be practically excluded from consideration. 

Prognosis. — When the disease reaches the stage at which signs of 
serious impairment of nutrition are noticed, evidenced principally by a 
dry, earthy-looking skin, the prognosis is very unfavourable ; and if 



730 DISEASE IN CHILDREN. 

hemorrhages occur, the end may be judged to be near. At an earlier 
period, when the spirits are fairly good, even although there be consider- 
able ascites, we may take a less gloomy view of the case. The more se- 
rious symptoms are sometimes found to clear away completely — for a time, 
at any rate, even if they subsequently return. 

In the case of hypertrophic cirrhosis, rapid alternations in the rapidity 
of the pulse, or drowsiness and nervous symptoms, are of very unfavour- 
able import. 

Treatment. — It is so seldom possible in the child to ascertain the exist- 
ence of hepatic cirrhosis in the earlier stage, that treatment at this period 
is confined to attention to the digestion, and to the efficient performance 
of the various organic functions. When the more characteristic symp- 
toms begin to be noticed, there are two forms of treatment which may be 
adopted. The patient may be treated with alkalies and aperients, or with 
tonics. On account of the gastric derangement, an alkali with a vegetable 
bitter is usually prescribed, and this mode of treatment answers very well 
in most cases. For a child of ten years old we may give eight or ten 
grains of bicarbonate of soda with infusion of chiretta or calumba ; and 
the addition of a few drops of the tincture of nux vomica increases the 
efficacy of the mixture. Most cases, however, do better under the use of 
iron and quinine. Ten or fifteen drops of the tincture of perchloride of 
iron with a grain of quinine given three times a day, and continued for a 
lengthened period, often seem to have great value in reducing the ascites 
and improving the general condition of the child. Mild aperients should 
also be made use of, and laxative doses of the Carlsbad or Hunyadi Janos 
waters are well borne in these cases. A good form of iron is the exsiccated 
sulphate, which agrees well with children. It must, however, be given in 
full doses ; and two to five grains, according to the age of the child, may 
be taken after each meal in a teaspoonful of glycerine. The diet should 
be liberal. It is well to allow meat twice a day ; and farinaceous foods 
may be used, having due regard to the state of the stomach and the 
child's power of digesting them. The action of the skin should be pro- 
moted by a daily warm bath, and the patient should be dressed from head 
to foot in flannel or some warm woollen material. 

The ascites is not benefited by the ordinary diuretics, but Dr. Basham's 
chalybeate diuretic, in which the iron is kept in solution by the acetic 
acid, 1 I have sometimes thought to be useful. 

If much fluid accumulates in the peritoneal cavity, and causes distress 
by interfering with the action of the diaphragm, the effusion must be re- 
moved by tapping the abdomen. The operation is accompanied by no 
danger to the child, if the aspirator or a fine trocar be used. It should be 
performed early and repeated as often as is necessary. Haemorrhages, 
unless they are copious, need not modify the treatment, but sufficient 
bleeding to manifestly weaken the patient must be combated with gallic 
acid, dilute sulphuric acid, and other styptics. Severe dyspeptic symptoms 
are best treated with bismuth and alkalies. 



1 1$ . Tinct. f erri perchloridi TI^ x. 

Acidi acetici diluti 1fT[ x. 

Liq. ammonise acetatis 3 ss. 

Aquam ad. § ss. 

M. ft. haustus. Sig. To be taken three times in the day. 



CHAPTER IV. 

AMYLOID LIVER. 

Amyloid, albuminoid, or lardaceous degeneration is a common lesion in 
the child, and the liver is often found to be enlarged from this cause. The 
liver, however, may not suffer alone. The spleen commonly, and the kidney 
frequently, are also affected ; and often there is a similar condition of the 
lymphatic glands. 

Causation. — The degeneration is always secondary to a general cachectic 
condition. It occurs sometimes in syphilitic children, and may be a conse- 
quence of scrofula and tubercle. The commonest cause is, however, the 
existence of chronic suppurations and purulent discharges. In fibroid in- 
duration of the lung, where there is a copious secretion in the dilated bron- 
chi, amyloid disease is a familiar symptom ; and in cases of empyema in 
early life, if a chronic fistulous opening become established, lardaceous de- 
generation of organs very generally follows. 

Morbid Anatomy. — The amyloid liver is uniformly enlarged, heavy, and 
excessively dense. Its edge is thin and resisting ; its peritoneal coat very 
smooth and tense. The section is dry and homogeneous looking, of a gray 
colour and a glistening bacony appearance. No blood oozes from the cut 
surface. If, as sometimes happens, there is concurrent fatty degeneration, 
the knife after the section may look greasy. The seat of the disease in the 
liver has been disputed. According to Meckel and Virchow it affects the 
liver-cells, while Wagner and others are of opinion that the amyloid change 
is confined to the capillaries, and that the cells are merely atrophied. Ac- 
cording to Rindfleisch, the morbid process begins in the arterial zone of the 
hepatic lobules, half way between the centre of the lobule and the circum- 
ference, and implicates the arteries, the capillaries, and the hepatic cells. It 
then spreads to the centre and afterwards to the circumference of the lobules. 
Kyber, too, declares that he has recognised the change in unmistakable liver- 
cells which he had isolated by pencilling. According to this pathologist, 
the trunk and larger branches of the hepatic artery are never affected, the 
morbid process being confined to the smaller hepatic arteries; but the 
change may be detected in the hepatic and portal veins, and even in the vena 
cava. The affected arteries and capillaries are diseased in various degrees. 
When the amyloid process is advanced in a vessel, its coats become thickened 
and pellucid ; and the affected hepatic cells lose their normal shape, their 
granules, bile-pigment, and nuclei, and become irregular and glassy looking. 
The addition of iodine solution stains the affected parts of a reddish brown 
colour, and sulphuric acid turns them first violet and afterwards blue. 

Symptoms. — Although the enlargement is perfectly painless, the organ 
may produce inconvenience by its weight. It causes distention of the belly ; 
but as there is no compression of the bile-ducts or of the branches of the 
portal vein, there is no necessary jaundice, ascites, or prominence of the 
superficial abdominal veins. All these symptoms may, however, be found. 



732 DISEASE IN CHILDBED. 

The mesenteric glands, like other internal organs, frequently participate in 
the amyloid degeneration ; and if the glands occupying the hepatic notch 
are enlarged, they may compress both the bile-ducts and the blood-vessels 
at this spot. In such a case, the skin, conjunctivae, and urine are jaundiced ; 
there is some effusion into the peritoneum, and the veins of the abdominal 
parietes are dilated. Even in the absence of jaundice, the stools may be 
light-coloured if the disease is advanced, owing to impaired function of the 
hepatic cells. 

On palpation of the belly, the liver is found to project several fingers' 
breadths below the margin of the ribs. Often its lower edge is on a level 
with the navel ; sometimes it reaches to the crest of the ilium. Its sub- 
stance feels firm and resisting, and its edge remains thin and sharp. There 
is no tenderness on pressure. In at least half the cases, the spleen, too, is 
enlarged, and can be felt several fingers' breadths below the ribs on the left 
side. 

Digestive disturbances may be noticed. There may be loss of appetite 
and vomiting ; and sometimes an obstinate watery diarrhoea comes on, due 
to amyloid degeneration of the intestine, or to tuberculous or scrofulous ul- 
ceration. The child is usually languid and easily tired. After exertion he 
is apt to look w 7 eary and haggard ; but if kept quiet, his face, although pallid, 
shows no signs of distress. Often his fingers and toes are clubbed. 

A constant symptom of amyloid disease is anaemia, and the poorness of 
blood is marked in proportion to the intensity of the degeneration. Con- 
sequently, in severe cases, the skin and mucous membranes are pallid, and 
some oedema of the legs and feet may be noticed. Still, no doubt, the kid- 
neys in many cases participate in the amyloid disease, and the anaemia and 
dropsy may be partially dependent upon the renal mischief. Albuminuria 
and casts may then be seen in the urine, but, as is elsewhere explained, 
these are not necessary symptoms of albuminoid kidney. 

Diagnosis. — Mere enlargement of the liver is at once detected by palpa- 
tion of the belly. It must be remembered that a hepatic swelling often 
presses up the diaphragm on the right side, and may cause dulness and 
weak breathing at the base of the right pulmonary region. Such signs 
(dulness and weak breathing) may be mistaken for signs of a pleuritic ef- 
fusion, more particularly as the signs are detected all round that side of the 
chest — in front as well as behind. A distinction may be made by noticing 
that in the case of an enlarged liver the dulness reaches up to a higher level 
in front than it does at the back (in pleurisy it is higher behind) ; that the 
dulness does not pass abruptly into resonance, as it would do in the case of 
fluid, for the thin border of the lung overlies the upper margin of the liver 
and produces a modified tubular or tympanitic note at that point ; and, 
lastly, that there is no alteration of the percussion-note in the dull area 
when the patient lies on his left side. A dull note replaced by resonance 
on change of position is characteristic of fluid ; and if the quantity of fluid 
be small, with little thickening of the pleura, this test of the effect of gravity 
upon the percussion-note will usually give satisfactory results in the child. 

A liver enlarged from amyloid degeneration is smooth and particularly 
firm and resisting. It often feels hard like wood. Its edge is thin and not 
rounded, and pressure upon it produces no uneasiness. Such a liver, un- 
accompanied by jaundice or ascites, and found in a cachectic, pallid child 
who has a syphilitic history, or has been the subject of bone disease or other 
form of prolonged suppuration, is in all probability albuminoid. If the 
spleen is also enlarged, and there is albuminuria with hyaline casts, there 
can be little doubt of the correctness of this opinion. Absence of splenic 



AMYLOID LIVER — PROGNOSIS — TREATMENT. 733 

dulness does not exclude albuminoid disease, for an amyloid spleen is not 
always bigger than natural. In half the cases the size of the spleen is not 
increased. 

Hepatic enlargement from congestion rarely occurs in cachectic, anse- 
mic children ; and a fatty liver is soft and yielding instead of hard and 
resisting ; moreover, it is not accompanied by enlargement of the spleen 
or albuminuria. 

Prognosis. — The presence of amyloid degeneration of the liver in any 
cachectic child must necessarily be considered as an additional element of 
danger. There is, however, reason to believe that this form of disease is 
of less serious augury in the young subject than it is in the adult, pro- 
vided that the source of irritation and suppuration can be removed. It 
is undeniable that in cases in which enlargement of the liver and 
spleen exactly resembling amyloid disease complicates old-standing ne- 
crosis of bone in scrofulous children, removal of the bone disease by a 
suitable operation is often followed by a return of the liver and spleen to 
their normal dimensions, and, to all appearance, by complete recovery of 
health. Mr. Barwell has recorded some remarkable cases of this kind. 
In one of these the urine was also albuminous and contained casts of tubes ; 
but after the operation the urine gradually became normal, and the dis- 
eased organs eventually returned to their normal size. It may be objected 
that in such cases the enlargement is not due to amyloid disease. That 
it is so cannot of course be proved, as the crucial test of dissection is 
wanting. It can only be said that the organs diseased are those com- 
monly diseased in albuminoid degeneration ; that the symptoms and 
physical signs are such as are found in cases of this form of illness ; and 
that the causes which are acknowledged to be powerful in producing al- 
buminoid lesions have been in operation. 

Treatment. — The treatment of amyloid degeneration consists, in the 
first place, in attending to the cause of the disease, and removing any long- 
standing suppurations and exhausting discharges which may be increasing 
the cachexia and adding to the weakness of the patient. If necrosis of 
bone or suppuration of a joint be present, the aid of a surgeon is required. 
Fibroid induration of the lung, or a chronic fistulous opening in the chest- 
wall, must be treated as directed in the chapters referring to these sub- 
jects. We must do our best, in the next place, to remove any secondary 
complications which may be helping to reduce the strength of the chilcl. 
The bowels must be attended to ; diarrhoea, if present, must be arrested, 
and if there be any reason to suspect scrofulous or tubercular ulceration 
of the intestinal mucous membrane, suitable remedies must be employed, 
as is elsewhere described. Vomiting must be checked by bismuth, dilute 
prussic acid, and the sucking of ice. 

For the liver itself, the preparations of iodine are very generally rec- 
ommended ; and as there is always more or less anaemia, iron may be 
judiciously combined with this treatment. I prefer giving the drugs 
singly, and have often prescribed (for a child of five years of age) five drops 
of the tincture of iodine to be given freely diluted before food, and five 
grains of the exsiccated sulphate of iron in glycerine directly after each 
meal. If the intestinal mucous membrane be healthy, this preparation of 
iron does not irritate, and given in sufficiently large doses, is of great value 
in the treatment of cachectic conditions in the child. If ulceration of the 
bowels be present, it is less suitable. The syrup of the iodide of iron so 
often disagrees, promoting acidity and flatulence, that I have long since 
abandoned its use. Iodide of potassium, combined with the citrate of iron, 



734 DISEASE IN CHILDREN. 

may be employed ; but the iodide should be administered in appreciable 
doses. It should be rarely given in smaller quantities than one grain for 
each year of the child's life. I cannot remember ever seeing any uncom- 
fortable symptoms, such as are common in the adult, produced by this 
remedy. Gardiner's syrup of hydriodic acid (TT[ xv.-xxx.) is also applicable 
to these cases. Dr. "Warburton Begbie speaks highly of the effects of mu- 
riate of ammonia in the adult. It may be given to the child in ten-grain 
doses freely diluted. 

The dropsy, being the consequence of the anaemia, must be treated 
with iron ; and the chalybeate diuretic of Dr. Basham, recommended else- 
where, 1 is here also of service. If the bowels are healthy, an occasional dose 
of the compound jalap powder will further the removal of the subcutan- 
eous effusions. 

The child must be put on a liberal diet suited to his age and powers of 
digestion ; and if the kidneys are not implicated, he will be benefited by 
stimulants. The St. Raphael tonic wine is useful in these cases. A suit- 
able climate adds greatly to the patient's chances of recovery. Dr. Begbie 
recommends a lengthened sea voyage ; and there is no doubt that condi- 
tions under which the child, warmly clothed, can pass the chief hours of 
the day in a fresh, bracing air, are the most favourable to permanent im- 
provement. German writers speak highly of the sulphurous springs of 
Aix-la-Chapelle, and the waters of Ems and Weilbach, in their influence 
upon this form of hepatic enlargement. 

1 See page 730. 



CHAPTER Y. 

FATTY LIVER. 

Fatty liver may be of two kinds. The one consists in a mere abnormal 
deposition of fat-globules in the hepatic cells without any injury or degen- 
eration of the cell- wall. This is called fatty infiltration. The other is fatty 
degeneration, in which the nutrition of the liver-cells is interfered with. 
They undergo a retrograde metamorphosis, and fat granules appear in them. 
Each of these varieties may be found in the child. They are most common 
in infancy and the earlier period of childhood. 

Causation. — Fatty infiltration of the liver may arise in the child from 
two causes : — From overfeeding with farinaceous foods, and from various 
forms of exhausting disease. In the first case, the hydrocarbon is supplied 
from without, and being in excess, is deposited in the liver in the form of 
fat. Deposition of fat under such circumstances may be looked upon rather 
as a physiological than a pathological process. It is often a merely tem- 
porary phenomenon, and ceases when the diet is changed. In the case of 
exhausting disease, such as tubercle, scrofula, intestinal catarrh, syphilis, 
rickets, etc. , the fat is reabsorbed from the subcutaneous and other fatty 
tissues. According to Oppenheimer, in infants dying during the second or 
third week of entero-colitis, the liver, although of normal appearance to the 
naked eye, is the seat of a real fatty degeneration. Fatty granules are seen 
in the hepatic cells along the whole course of the portal vessels, and the de- 
generation is preceded by the formation of an abnormal plasma in the cells 
which completely obscures the nuclei. In other structural diseases of the 
liver, fatty degeneration may occur as a secondary lesion. 

Morbid Anatomy. — The size of the liver is not altered unless the fatty 
change is carried to a high degree. In that case all its measurements are 
increased and its edge is blunted. The surface is lighter coloured than 
natural, and may have an oily, shining appearance. The hepatic substance 
feels soft and doughy to the touch, and the section is yellowish red or 
yellow. In extreme cases the blade of the knife looks greasy after the sec- 
tion. By the microscope granules and globules of fat are seen in the he- 
patic cells. The oily drops are larger in proportion to the stage to which 
the infiltration has advanced ; and if the process be carried to a high de- 
gree, the cells may each be filled by one large drop of oil. The cells at the 
circumference of the lobules near to the intra-lobular veins are first and 
principally affected. Those towards the centre are much more healthy. 
Therefore, on closely inspecting a lobule, the part immediately surrounding 
the central vein will be found much redder in colour than the periphery. 
The fat consists of olein and margarine, with traces of cholesterine. 

Symptoms. — If the organ is not enlarged, and the degree of fatty infil- 
tration is slight, symptoms may be absent altogether. Even if the liver is 
enlarged, there is little to draw attention to the belly. Some tenderness 
may be noticed in the right hypochondrium when this is pressed, and in 



736 DISEASE IN CHILDREN. 

exceptional cases the child may complain of a feeling of heaviness on that 
side. Cases where the size of the liver is notably increased from this cause 
are usually those of phthisical children. There may be some digestive de- 
rangement from interference with the portal circulation, but there is never 
jaundice or ascites. The fatty liver is not always easy to feel, as it yields 
readily under the finger, and is easily depressed from the surface. Conse- 
quently, like the softened spleen in typhoid fever, its edge may elude the 
touch. It is of the utmost importance, in consideration of cases such as 
these, to lose no opportunity of practising the sense of touch and accustom- 
ing the finger to appreciate slight differences in resistance. 

In fatty degeneration of the liver, there is no increase in size of the or- 
gan, and the disease, occurring as it does in the course of some exhausting 
illness, gives rise to no symptoms which can reveal its presence. It is there- 
fore seldom discovered during life. 

Diagnosis. — A liver enlarged from fatty infiltration differs from other 
forms of enlarged liver. Instead of being firm and resisting, its substance is 
soft and yielding ; and the edge, instead of being sharp and thin, is rounded 
and blunt. Such a liver found in a case of tubercular or scrofulous phthisis, 
or in the course of some other exhausting disease, unaccompanied by jaun- 
dice, ascites, or dilatation of the superficial veins of the abdomen, is in all 
probability fatty. Thus, in a little girl, aged three years, the subject of a 
chronic hydrocephalus, who died in the East London Children's Hospital 
from acute tuberculosis, the liver on the child's admission was found to 
reach as far downwards as the level of the umbilicus. Its edges were 
rounded and its substance seemed to be normal. There was no sign of 
jaundice ; the superficial veins of the belly were not visible, nor could any 
fluctuation be detected in the abdomen. The spleen was also enlarged. 
After death, the liver was found to be greatly increased in size. Its con- 
sistence was softer than natural, its colour a fawn brown, and some yellow 
miliary nodules were seen on the surface. Its section had a greasy look. 
The spleen, which was also enlarged, was studded with tubercles. 

Prognosis. — A remarkably fatty liver occurring in the course of a linger- 
ing illness implies serious interference with nutrition ; but the prognosis 
depends more upon the primary disease than upon the state of the liver. 

Treatment. — The indications for treatment must be derived from the 
primary disease in the course of which the fatty condition of the organ has 
arisen. If a child is known to be taking extravagant quantities of farina- 
ceous food, measures must be taken at once to put a stop to such excess ; 
but many other symptoms besides fatty liver may be the consequence of 
such a dietary. This subject is treated of elsewhere (see Gastric Catarrh). 



CHAPTER VI. 

HYDATID OF THE LIVER. 

Hydatid of the liver is sometimes found in childhood. The disease sel- 
dom occurs earlier than the fourth year of life, although Cmveilhier has 
quoted a case in an infant twelve days old, and M. Archambault has 
seen it in a child aged three years and a half. Between the fourth and 
eighth year it is sometimes met with, but is still rare. After the eighth 
year it is more common. The earliest age at which the disease has come 
under my own notice has been five years and a half. 

Causation. — The hydatid growth becomes implanted in the human liver 
as a result of the introduction into the stomach and intestines of the ova 
of the tenia echinococcus. This creature is a parasitic worm inhabiting 
the alimentary canal of the dog and wolf. The tape-worm is a quarter of 
an inch in length, and has four joints, the last of which (the proglottis or 
sexually mature segment) contains the ova. The ova are excreted by the 
animal in whose intestines they have found a lodgment, and contaminating 
water or articles of food, become introduced into the human body. It is 
probable, also, that the ova and scolices may be sometimes conveyed to the 
child directly. In the dog, the presence of the worm in the bowels, and 
the passage of the eggs and embryos in large numbers through the anus^ 
causes considerable irritation, which the animal endeavours to relieve by 
licking. If directly afterwards he apply his tongue to the face and mouth 
of the child, the parasite may pass at once to the child's tongue and be 
swallowed. How it travels from the alimentary canal to the liver is not 
clear. 

Hydatid disease is endemic in Iceland, where the children are often af- 
fected. The enormous number of dogs maintained on the island has been 
supposed, with much probability, to be the explanation of the frequency 
of the disease. 

Morbid Anatomy. — Hydatid tumours are more common in the liver 
than elsewhere in the body ; but from the intestine they may pass not 
only into the liver but also into the spleen, the mesentery, the wall of the 
abdomen, and even into the substance of the heart and brain. The liver 
may contain one sac or several. The sac itself consists of a firm fibrous 
capsule in close adherence to the liver substance, and is very vascular. 
Inside the capsule there is a clear gelatinous bladder (the envelope of the 

r esicle) composed of numerous fine concentric strata. This is the mother 
sac. It contains numerous large and small vesicles floating in a clear fluid, 
or adherent to the investing envelope. Some of the larger of the daughter 
vesicles may contain smaller sacs still of a third generation. These are 
seldom larger than the head of a medium-sized pin. The mother sac itself 

r aries in size from a pea to a marble, an orange, or a child's head. The 
fluid it contains is non-albuminous and holds in solution salts, principally 
the chloride of sodium. On careful examination of this fluid, the booklets 
47 



738 DISEASE IN CHILDREN. 

of the embryos (scolices) of the taenia echinococcus may be often recog- 
nised by the microscope. 

The scolices themselves may be sometimes found. These are from qne- 
twentieth to one-sixth of a line in length. The head, which resembles 
that of the taenia, has four suckers and a trunk. The latter is encircled 
by a double crown of hooklets, the number of which varies, according to 
Kuchenmeister, from twenty-eight to thirty, or from forty- six to fifty-two. 
The head is separated from the body by a groove, and at its posterior end 
is a depression into which a cord is inserted. This attaches it to the inner 
wall of the sac. The shape varies according as to whether the head is 
stretched out or retracted. On the body, elongated lines are seen passing 
backwards from the head. These are intersected by transverse stria?. 
Besides these markings, a number of rounded calcareous corpuscles can 
be detected. The scolices lie in groups on the inner wall of the cyst, and 
can be seen through the vesicular wall as delicate white particles. Some- 
times the mother sac contains scolices but no daughter vesicles. Some- 
times it contains neither vesicles nor embryos. 

The sacs may be seated at any part of the liver, but are more common 
in the right lobe than in the left. The liver is generally enlarged by 
them, and may appear uniformly swollen if the sac is deep-seated. If 
superficially placed, the cyst raises a bump or tumour at the correspond- 
ing part of the surface. When it lies close under the peritoneal coat of 
the liver, this membrane becomes thickened and may form adhesions with 
parts around. The pressure of the sac upon the parenchyma of the organ 
causes destruction and atrophy of the hepatic tissue. The larger blood- 
vessels and bile-ducts are seldom affected ; but occasionally the ducts may 
be obliterated, or a communication may be formed between the sac and a 
large duct or blood-vessel. In such cases the death of the cyst usually fol- 
lows. 

After a time changes generally take place in the mother sac. It may 
rupture from over-distention, and only a few shreds of the original vesicle 
may be left amongst the daughter cysts. Sometimes the sac suppurates, 
or is converted into semi-solid atheromatous matter composed of phosphate 
and carbonate of lime, cholesterine, and a substance resembling albumen. 
In other cases adhesions may be formed with neighbouring parts, and the 
cyst may burst into the stomach or bowels, or through the diaphragm 
into the pleura or lung. Accidental injuries have caused rupture of the 
cyst and extravasation of its contents into the peritoneal cavity. In rare 
cases the hydatid sac has been known to open externally through the ab- 
dominal parietes or a lower intercostal space. After escape of the fluid by 
any of these means, suppuration of the cyst may still take place, and 
pyaemia is one of the consequences which may result. Sometimes, al- 
though rarely, the increase in thickness of the capsule, which may acquire 
a cartilaginous consistence, so interferes with the development of the 
echinococcus that death ensues and a spontaneous cure is effected. This 
however, is not likely to occur except in hydatids of small size which have 
not been detected during life. 

Symptoms. — When the cyst is small and is planted deeply in the sub- 
stance of the liver, it may give rise to no symptoms at all. In most cases, 
however, the liver becomes enlarged, but not uniformly. A tumour is felt 
at one part of the organ which may project upwards into the chest or down- 
wards into the belly. The swelling is painless as a rule, and may give rise 
to no uneasiness, but a feeling of weight. It is smooth, round, often elas- 
tic, and may convey a distinct sense of fluctuation. Sometimes, however, 



HYDATID OF THE LITEE— SYMPTOMS. 739 

as in a case to be afterwards narrated, it feels firm and solid like a fibrous 
growth. In exceptional cases a sense of vibration, first described by Horry 
as the " hydatid fremitus," is felt by sharply percussing the finger allowed 
to rest upon the tumour. This vibration, according to Dr. Sadde, denotes 
the presence of daughter vesicles. Therefore, if vibration is absent, we 
should expect to find few or no hooklets. Occasionally, pain has been no- 
ticed from mere distention, as in a case mentioned by Frerichs, where the 
pain ceased after puncture and removal of a quantity of watery fluid from 
the cyst. As a rule, pain, if present, indicates inflammation and suppura- 
tion of the sac. 

As the tumour seldom interferes with the channels of the bile-ducts or 
portal vessels, jaundice and ascites are rare, and dyspejotic symptoms are 
seldom observed. In ordinary cases, therefore, the nutrition of the child 
is not interfered with, and there is no fever. The patient is brought for 
advice merely on account of the unusual size and unilateral hardness of his 
belly. In young subjects the projection, as a rule, is readily detected by 
the eye. and if seated near the convex surface of the right lobe, as it usu- 
ally is, forms a swelling which protrudes downward from beneath the lower 
ribs. 

A little boy, aged five years and a half, was brought to me at the hos- 
pital on account of the size of his belly and occasional pains which he com- 
plained of in the right hypo chondri urn. He had, besides, some cough in 
the morning. On examination of the abdomen, a prominent swelling was 
discovered in the hepatic region, bounded above by the ribs, and below by 
a line drawn just below the level of the navel. Its transverse measurement 
was three and a half inches. The liver dulness began above one fingers 
breadth below the nipple, and its lower edge could be felt just below the 
lower border of the tumour. The swelling was smooth, elastic, and gave a 
semi-fluctuating sensation to the finger. There was no hydatid fremitus. 
When pressure was made upon it, the child flinched and said it was sore. 
There was no jaundice, ascites, or prominence of the superficial abdominal 
veins. The swelling was punctured with the pneumatic aspirator through 
the abdominal parietes, and about an ounce of purulent matter was evac- 
uated. No hooklets could be detected. Ten days afterwards the cyst had 
refilled. It was again punctured, and a quantity of perfectly clear fluid 
escaped. The cyst did not again refill, and the size of the liver was greatly 
reduced when the child left the hospital. 

Sometimes the tumour, instead of becoming visible in the belly, may 
press upwards the right side of the diaphragm and the base of the lung, 
and project far into the right side of the chest. In such a case the lower 
ribs on that side are pushed outwards, and the physical signs very much 
resemble those of a pleuritic effusion. Even if the tumour project but 
slightly upwards, the respiratory sounds are usually very weak at the right 
posterior base of the chest, and the percussion-note may be a little higher 
pitched, with increased sense of resistance. 

If, instead of projecting from the convexity of the organ, the hydatid 
sac protrudes from the under aspect of the liver, pressure signs may be 
observed in connection with the biliary and vascular conduits. It is in 
these cases that jaundice, ascites, and oedema of the feet may be noticed. 

If spontaneous suppuration take place in the hydatid sac, the symptoms 
vary in severity. They may be grave or trifling. In some cases a slight 
rise in the temperature of the child occurs ; he looks a little poorly ; 
coughs, and complains of pain when his belly is manipulated, but nothing 
is noticed to excite the alarm of the parents. In other cases he shivers, 



740 DISEASE IN CHILDREN. 

and his temperature undergoes the rapid alternations peculiar to suppura- 
tion ; the swelling increases in size, and, if left alone, either points at some 
part of the surface, or sets up adhesive inflammation with a neighbouring 
organ and bursts into it. The proof that such an abscess is the result of a 
hydatid cyst is the finding of hydatid membranes or hooklets in the evac- 
uated pus. 

If the cyst be not interfered with, it will probably in time destroy the life 
of the patient by bursting into some neighbouring organ. Bohn has related 
the case of a child eight years of age, in whom the sac burst into the bowel. 
The patient recovered ; but a favourable issue to so severe a complication 
must be rare. The cyst usually bursts into the cavity of the chest — into 
the pleura or the lung. Death is a frequent consequence of either acci- 
dent. In the latter case pneumonia is set up, and the patient dies worn 
out by the profuse discharge. 

Hydatid of the liver may be complicated by a similar development in 
the spleen, in the folds of the mesentery, or beneath the peritoneum. It 
is important to be aware of this possible distribution of the echinococci, as 
the presence of various tumours in the abdominal cavity may tend to em- 
barrass the diagnosis. Sometimes the lungs as well as the liver are af- 
fected. These various cysts often appear to be of different ages, and in 
that case may arise from absorption of embryos at different periods of 
time. It has been suggested that germs generated by the elder hydatids 
may be carried along by the current of blood and deposited in other 
organs ; but in this case they could hardly be conveyed from the liver to 
the spleen or mesentery against the direction of the blood-current. 

Diagnosis. — The diagnostic features of a hydatid tumour of the liver 
are : — A localised swelling of the organ, smooth, elastic, and painless, ac- 
companied by no signs of jaundice, ascites, prominence of the superficial 
abdominal veins or swelling of the feet, and giving rise to no pyrexia or 
impairment of the general health of the child. If the characteristic frem- 
itus can be detected on percussion of the swelling, the evidence is com- 
plete. 

If suppuration have occurred in the sac there may be some fever, and 
the child looks ill and pale. Pain maybe complained of in the right hypo- 
chonclrium, and the tumour may be tender when pressed upon. 

If the tumour feel solid to the touch, as was the case in a child who 
was under my care in the hospital, the diagnosis would rest upon the 
slow growth and painless condition of the swelling, and the general 
absence of symptoms. I have never met with a sarcoma or soft cancer of 
the liver in a child, but it is possible that this disease might be mistaken 
for a hydatid cyst. The growth, however, would be more rapid in such a 
case, and we should expect to find some impairment of the general health. 
In any case of doubt an exploratory puncture with a fine trocar and can- 
ula will remove all hesitation. If a non-albuminous, clear, or slightly 
turbid fluid escape, especially if hooklets can be discovered in it by the 
microscope, the diagnosis of hydatids is clear. 

If a large cyst project upwards into the chest and compress the base of 
the lung, it is often mistaken for a pleuritic effusion. The error is one 
which is easily fallen into, for in both cases there is complete dulness, with 
increased sense of resistance and weak breathing, all round the right side 
of the chest. A distinction may be made by observing that in the case of 
a hepatic cyst the upper line of dulness is curved with the convexity up- 
wards, and that the dulness, therefore, reaches higher in the mid-axillary 
line than at either the front or the back of the chest. In pleurisy an 



HYDATID OF THE LIVER — PROGNOSIS — TREATMENT. 741 

exactly opposite condition is found. The upper margin of dulness is con- 
cave, being less elevated in the infra-axillary region than at the back. If 
there is any suspicion that the disease is not pleurisy, an exploring trocar, 
allowing of examination of the fluid, will soon set the matter at rest. The 
fluid drawn from the chest in pleurisy coagulates on boiling, while the 
hydatid fluid, as has been said, is non-albuminous. 

In the rare cases where jaundice and ascites are produced by a hydatid 
cyst placed near the concavity of the liver, no localised swelling can be de- 
tected, and a diagnosis is hardly possible unless we can satisfy ourselves 
by puncture or otherwise of the presence of a similar cyst in other organs. 

Prognosis. — If the child is seen before injury has been inflicted upon 
neighbouring organs by bursting of a hydatid sac into them, the prog- 
nosis is favourable ; for the slight operative procedure necessary for the 
evacuation of the fluid and destruction of the cyst and its contents is 
usually well borne. If the sac has been evacuated into a neighbouring 
organ, the situation is a very serious one, and most of these cases prove 
fatal. 

Treatment. — Although many internal remedies have been administered 
in the hope that the drug might pass from the blood to the interior of the 
cyst, and so destroy the life of the hydatid, it is now admitted that such an 
object is not to be attained by physic. Our only means of curing the 
patient is to puncture the cyst and evacuate its contents. If this be done 
with a fine trocar and canula, there is little risk of escape of the fluid into 
the peritoneum, and consequent peritonitis. It is best to employ the 
pneumatic aspirator, so as to prevent the entrance of air into the sac. 
After the withdrawal of its fluid contents, the hydatid cyst collapses and 
its membrane shrinks away from the investing capsule. The resulting 
space is rapidly filled by exuded serum, and the hydatid quickly dies. 
Sometimes the operation requires to be repeated. It is usually unneces- 
sary to employ irritating injections after emptjdng the sac, but if the cyst 
continually refills, it may be desirable to do so. 

A healthy-looking, well-nourished girl, aged twelve years, was under 
my care in the Victoria Park Hospital, for a swelling in the right side of 
the belly which had been first noticed two months previously. 

On examination it was seen that the lower ribs on the right side were 
distinctly prominent, and that the intercostal spaces at that part were wi- 
dened. The liver dulness began at the lower border of the fourth rib, and 
the inferior edge of the organ could be felt just below the level of the 
umbilicus. Immediately below the ribs, a solid-feeling tumour was dis- 
covered. This gave no elastic sensation to the finger, and was not at all 
tender when pressed upon . It descended somewhat on deep inspiration. 
Below it the substance of the liver could be felt of normal density, convey- 
ing to the finger a very different sensation to the solid resistance of the 
tumour. Posteriorly, the hepatic dulness began at the lower angle of the 
scapula, and complete dulness one interspace lower down. The respira- 
tory sounds were weak at the right base behind, and some friction was 
heard in the infra-axillary region and at the base in front (the child had 
had pleurisy eighteen months before). There was no jaundice or ascites, 
and the superficial veins, although more visible than natural over the front 
of the chest, were not dilated in the epigastrium or on the abdominal wall. 
The heart's apex was in the fifth interspace in the nipple line. Its sounds 
were healthy. 

An exploratory puncture was made in the tumour with a hypodermic in- 
jection syringe, and some colourless fluid containing chlorides but no albu- 



742 DISEASE IN C1IILDKEST. 

men was withdrawn. No hydatids could be discovered in the fluid by the 
microscope. Some days afterwards the tumour was again punctured with 
the aspirator through the eighth interspace, and twenty ounces of a clear, 
straw-coloured fluid were withdrawn, having the characters above men- 
tioned. Its specific gravity was 1.008. No hooklets could be seen under 
the microscope. A solution of iodine (half a drachm of the tincture to 
half an ounce of water) was then injected into the cyst, and the child took 
a draught containing five drops of laudanum. 

The operation was followed by no rigors, sickness, or other sign of dis- 
comfort ; but the temperature rose every night to between 101° and 102°, 
sinking in the morning to nearly the normal level. A fortnight after the 
first operation, the tumour being rather more prominent than on the 
child's admission, the cyst w r as again punctured, and twenty-three ounces 
of thick greenish pus were drawn off. In another fortnight the operation 
was repeated for the third time, removing eleven ounces of greenish pus. 
This was quite sweet, and under the microscope showed hooklets and signs 
of hydatid debris. On each of these occasions the cyst had been tapped 
through the chest- wall ; but ten days after the last operation, the cyst hav- 
ing again refilled, the needle of the aspirator was introduced through the 
abdominal parietes and twenty-three ounces of pus were evacuated. The 
operation set up some local peritonitis ; but this was quickly reduced by 
poulticing and the administration of six drops of laudanum three times a day. 

After the last operation the cyst did not fill again, and when the girl 
left the hospital a month afterwards, there was slight curving of the spine 
with the convexity to the left ; the right shoulder and angle of the scapula 
were a little depressed ; the edge of the liver was felt one inch above the 
umbilicus, and its upper border was on a level with the nipple. Its sub- 
stance felt normal to the touch, and there was no distention or tenderness 
of the belly. Six months afterwards, when the child was seen again, the 
liver had returned to its normal size ; the spine was perfectly straight ; 
the shoulders were on the same level, and no indication was left that the 
girl had ever been ill. 

Injection of iodine after the evacuation of the contents of the sac is not 
necessary to the success of the operation. It is usually found that simple 
emptying of the cyst is sufficient to destroy the life of the hydatid and that 
irritating injections are useless. In every case the child should be kept 
very quiet for a day or two after the puncture, and a firm bandage should 
be applied to the belly. It is well, also, to give a little opium at night, as 
was done in the case above narrated. 

A sufficient time should be allowed to elapse after evacuating the fluid 
before repeating the operation. The cyst will often seem to be filling up 
again for a time ; but, if left alone, it frequently subsides without further 
interference and gradually becomes obliterated. 

Dr. Fagg has reported several cases of hydatid tumour of the liver in 
children which he had treated by electrolysis in the manner recommended 
by Dr. Althaus. The operation was performed by passing two electrolytic 
needles into the cyst, one or two inches apart. The needles were then at- 
tached to two metallic wires both connected with the negative pole of a 
galvanic battery of ten cells. A moistened sponge formed the termination 
of the positive pole ; and this was placed on the patient's skin, at a little 
distance from the points of entrance of the needles. Its position was 
changed. from time to time during the operation. After the current had 
passed for about ten minutes, the needles were withdrawn and adhesive 
plaster was applied to the seats of puncture. 



HYDATID OF THE LIYEE — TREATMENT. 743 

The operation was usually followed by a little febrile disturbance and 
some pain ; but no immediate effect upon the size of the tumour was dis- 
coverable. Indeed, the children were sent away from the hospital in much 
the same state as when they were admitted. But examination, after a 
period of months, usually detected considerable diminution in the dimen- 
sions of the cyst. The operation appears, therefore, to be attended by no 
danger ; but its results are too slow in making themselves manifest to ren- 
der it suitable for adoption in private practice. With regard to the modus 
operandi of the procedure, Dr. Fagg suggests that the gradual subsidence 
of the tumour may be due to slow oozing of the hydatid fluid through the 
punctures made by the needles ; for hydatid fluid alone, unaccompanied 
by ova or scoliees, appears to be innocuous when extravasated into the 
peritoneum. 

If suppuration have occurred in the sac, and the matter withdrawn be 
putrid and offensive, the cyst must be washed out frequently with a weak 
antiseptic solution ; opium should be given to allay pain and irritation ; and 
quinine in full doses, with nutritious diet and stimulants, will be required. 



Part 11. 
DISEASES OF THE GENITOURINARY ORGANS. 



CHAPTER I. 

THE URINE. 



On account of the difficulty of collecting the urine in very young children, 
it is seldom possible to estimate the average quantity passed in the twent} T - 
four hours. It is not always easy to obtain the quantity necessary for ex- 
amination of its chemical characters. 

In health, the water is clear, light-coloured, and of low specific gravity ; 
but it is subject to frequent variations on account of the readiness with 
which the child responds to every disturbing agency. The quantity secreted 
is dependent upon certain conditions, such as : — The degree of blood-press- 
ure in the renal arteries ; the facility with which the urinary tubules dis- 
charge their contents ; and the state of the nervous system generally. Also 
upon the condition of the other emunctories of the body, the quantity of 
fluid taken, and lastly, upon the state of health of the individual. Con- 
sequently the water passed varies greatly in amount. Sudden copious se- 
cretion may be a temporary symptom in many cases of digestive derange- 
ment ; in particular, attacks of severe abdominal pain are often terminated 
by a copious flow of almost colourless urine from the bladder. Also, an 
epileptic seizure, an attack of ague, or a fit of convulsions in the child may 
be followed by a profuse secretion of limpid urine. Various articles of 
food seem to have a direct action in promoting secretion from the kidneys. 
In some children barley-water has this effect ; and the nurse complains 
that while taking it, the child is almost " constantly wet." Again, certain 
diseases are accompanied by an increased flow of urine. Diabetes mellitus, 
and diabetes insipidus are in rare cases seen in children. The former, 
however, uncommon at any age under puberty, is almost unknown under 
five years of age. The latter is sometimes an accompaniment of gastro -in- 
testinal disorders, but ceases usually when the digestive organs have been 
put into a better condition. 

Diminution in the quantity of water passed is the result of many dif- 
ferent causes, and usually attracts more attention than the opposite condi- 
tion. The skin in some children acts very freely ; and in warm weather a 
large proportion of the fluid may leave the body by this channel. In such 
a case the urine may be very scanty. One morning in July a child aged 



THE URINE — VARIATION IN QUANTITY. 745 

ten months was brought to me on account of, the small quantity of urine 
she was passing. During the preceding twenty-four hours she had passed 
water but once, and then in very small quantity on the evening before the 
visit. The weather was very warm, and the child perspired profusely, but 
except for slight costiveness was and seemed perfectly well. I quieted the 
alarm of the mother, advised that the child should be given plenty of fluid, 
and ordered a gentle aperient to relieve the bowels. After this, the mother 
was soon made happy by seeing a more copious secretion of urine. The 
amount of water is also diminished by diarrhoea and vomiting, which de- 
rangements, as in the preceding case, divert a certain quantity of water from 
the kidneys. When the reduced secretion is due to a watery flow from the 
bowels, it may be unnoticed by the attendants ; but when the symptom is 
an accompaniment of vomiting, the small quantity of water passed from the 
bladder is often a cause of anxiety. In cases of extreme prostration from 
deficient nourishment in infants, the secretion of urine is scanty and may 
be completely suppressed. Indeed, Dr. Parrot attributes the cerebral 
symptoms which sometimes occur in such cases, and are called "spurious 
hydrocephalus," to toxic causes, the blood being charged with excrementi- 
tious matters which it cannot get rid of. In the febrile state, the urinary 
water is diminished in quantity, and is increased again as the temperature 
subsides. There is, however, no reduction in the solid constituents of the 
urine, and the specific gravity is consequently raised. Besides the above 
causes which act through the system generally, other and local causes 
which interfere with the secreting function of the kidneys may have the 
same result. Thus, congestion of the kidneys from disease of the heart or 
liver, and Bright's disease, may reduce the quantity of water to a very 
small amount. 

Variations occur not only in the quantity of water passed from the kid- 
neys, but also in the amount of solid matters excreted. Thus, in febrile 
diseases the urine is not only more concentrated from deficiency of water, 
but it is richer in urea and uric acid, although poorer in chlorides. In health 
the quantity of urea passed by a child is relatively greater than it is in the 
adult. According to Uhle, children between three and six years of age 
pass in the twenty-four hours one gramnie of urea for each kilogramme of 
their weight. This fact is important as indicating the active metamorpho- 
sis of the protein compounds of the body which occurs in early life. 

It has been said that the water of a young child in perfect health is 
quite clear. In the normal state it is also slightly acid. Very slight causes 
will give rise to an increase in the amount of acid secreted, and the water 
is then apt to be thick with lithates. As in older persons, the turbidity 
generally occurs as the urine cools on standing ; but sometimes it is turbid 
while still warm, and may even be passed thick from the bladder. Infants, 
especially, sometimes alarm their mothers by voiding water thick and 
milky-looking from a profuse secretion of urate of soda. The appearance 
of a deposit of lithates may be due to two causes : — To increased secretion 
of the salts, and to excess of acid in the water. Young children who are 
habitually overfed continually pass water loaded with lithates ; and if they 
are taking inordinate quantities of fermentable material in their food, the 
amount of acid is also greater than normal. Thus, both the causes whicli 
conduce to turbidity of urine are present. During convalescence from 
acute disease in a child, when it is our object to further the return of flesh 
and strength by an ample supply of nourishing food, and at the same time 
to avoid overburdening the digestive organs by an excess of nutritive ma- 
terial, the state of the water offers a very good index as to whether the 



746 DISEASE IN CHILDREN. 

necessary quantity has been exceeded. If the child is eating too much, 
his water becomes at once thick with lithates, and warns us to make some 
reduction in the quantity, or alteration in the quality of his meals. 

Besides lithates, young children, and even infants, may pass free uric 
acid in their water. This subject will be considered afterwards (see Cal- 
culus of Kidney). 

The urine in infants is sometimes noticed to be very offensive. This is 
due to a catarrhal condition of the bladder, and denotes rapid decomposi- 
tion of the urea. Another symptom sometimes complained of by the 
mother is that the water is very dark in colour and causes stains on the 
diaper. This may be the consequence of the presence of bile-pigment in 
the urine. 

Albumen is often found in the urine of children, but must not be looked 
upon as in every case indicating disease of the kidneys. It is seen in 
many inflammatory complaints and fevers, as in pneumonia, diphtheria, 
measles, typhoid fever, etc. In such cases it is probably dependent either 
upon an altered condition of the blood, when it is an expression of the 
general disturbance of the system induced by the illness, or upon an in- 
fectious nephritis, which is found, according to M. Bouchard, in many 
forms of acute specific fever. Again, a casual admixture of blood or pus 
with the urine may give rise to the presence of albumen, as in cases of ir- 
ritation of the urinary passages by calculous concretions. Passive conges- 
tion of the kidneys, such as takes place in many cases of heart disease and 
in some forms of bronchitis, may be a cause of the same symptom, and 
the albumen may be accompanied by epithelial and blood casts. But 
in these cases the presence of the albumen, and even of the casts, is no 
indication of organic disease of the kidneys. We are only justified in 
inferring the existence of renal disease when we find by the microscope 
hyaline or granular casts in conjunction with the albuminuria. A transient 
albuminuria is sometimes met with, and appears to be a result of some 
bodily derangement quite independent of renal disease. It may be found 
in school-boys who are preparing for examination. Dr. Kinnicutt at- 
tributes it in many cases to a transient oxaluria or lithuria. It has also 
been seen in ague districts as a consequence of malaria. Intermittent al- 
buminuria — albumen being abundant one day, absent the next — is usually 
due to an admixture of secretions, and should lead us to suspect a habit of 
masturbation. 

As in older persons, the urine of children and even of infants may con- 
tain blood. This may be poured out from any part of the urinary passages. 
When the source of the blood is the urethra or bladder, the two fluids are 
passed separately without mingling together. Thus, in a case of vesical 
calculus, the child passes first water and then a little blood from the 
bladder. When the two fluids are intimately blended, we are justified in 
concluding that the blood comes from the kidney. Kenal haemorrhage is 
not very uncommon in young subjects, and may occur in large or in small 
quantity. When in large quantity — in quantity sufficient to give a dark 
red colour to the whole volume of urine — the blood may be usually ascribed 
to one of two causes ; either to hemorrhagic purpura or to irritation of 
the kidney by calculous concretions. In the first case there are signs of 
haemorrhage from other mucous passages and into the skin. In the second, 
the child may complain of no pain, and appear, except for the haemorrhage, 
to be perfectly well. In smaller quantities, often enough merely to give a 
smoky tint to the urine, hematuria is seen in acute Bright's disease, in 
hemorrhagic measles, in scarlatina, diphtheria, and small-pox ; sometimes, 



THE URINE — HEMATURIA. 747 

also, in ague. Even after suppression of urine in young children suffering 
from inflammatory diarrhoea, the renal secretion, when the function of the 
kidneys is restored, may contain blood. In fact, wherever albumen is 
present in the urine blood may be present as well. In all such cases the 
blood-corpuscles may be recognized by the microscope. Occasionally, es- 
pecially in scarlatina before the appearance of albuminuria, the urine may 
contain the colouring matter of the blood, but without any of the corpuscles 
being discovered by microscopical examination. 

There is a form of hematuria which is common in some parts of Africa, 
especially in Egypt and the Cape of Good Hope. The haemorrhage is due 
to the presence of the Bilharzia haematobia (genus Hematoda). This para- 
site is found in the portal and mesenteric veins, and in the kidneys and 
urinary passages. According to Dr. James F. Allen, almost every boy in 
Natal suffers or has suffered from this parasite, for the embryos develope 
in water and abound in the running streams. The girls, who stay more at 
home and drink filtered water, commonly escape. The creatures enter the 
system by the stomach from drinking the water, or by passing directly 
into the bladder through the urethra while the boy is bathing. Amongst 
the natives of South Africa a practice is said to prevail, before entering the 
water, of tying a piece of tape round the end of the penis to prevent the 
entrance of the parasite. 

The haemorrhage appears to come from the bladder. After micturi- 
tion a little blood is passed from the urethra. The quantity is often 
only a few drops, but may reach several ounces. It occurs on each occa- 
sion at the end of the flow of urine. Its passage is nearly always accom- 
panied by a rigor, and sometimes by pain and irritation referred to the 
bladder. On examination of the urine it is found always to contain 
blood, more or less albumen, and a quantity of mucus. In severe cases 
its reaction is alkaline, and it contains triple phosphate crystals. Under 
the microscope the ova of the bilharzia are seen entangled in the blood- 
clots and free among the blood-corpuscles. They are T ^ ¥ inch long, ovoid 
in form, and have a spike at one extremity. If the ovum is broken under 
the microscope, by pressure of the two glasses against one another, the 
living embryo may be seen to emerge from its shell. It is ovoid in shape, 
like the egg, is pointed at one extremity, and projecting from the sides are 
innumerable cilia, which seem to be always in motion. 

The result of the constant loss of blood soon manifests itself. The 
boy, although tall, is pale and" narrow-chested. He has little appetite, is 
listless, and shows no energy, either mental or physical. Children are said 
to begin to suffer from the parasite at a very early age ; but soon after 
puberty the haemorrhage ceases and the patient recovers. It appears 
never to be fatal. 

Dr. Allen states that internal treatment of every kind, although it 
may destroy the parasite in the blood, fails to influence the local symp- 
toms or arrest the haemorrhage. To do this local treatment is necessary. 
He advises the injection into the bladder of a saturated solution of san- 
tonine in absolute alcohol. Of this, a quantity varying from half a drachni 
to two drachms must be used when the bladder is empty, and must be re- 
tained as long as possible. The injection sets up a mild cystitis, which 
should be treated with hyoscyamus and infusion of buchu. If the larger 
quantity of santonine be used, the patient feels drunk from the remedy 
affecting the brain, and the cystitis lasts three or four days, instead of 
merely one or two ; but no other ill effects are noticed. The injection may 
have to be repeated several times, but is invariably successful in the end. 



748 DISEASE IN CHILDREN. 

Afterwards santonine should be given by the mouth to destroy any em- 
bryos remaining in the blood. 

Besides santonine other local applications have been suggested. Iodide 
of potassium and the liquid extract of male fern are both well tolerated 
by the bladder. Dr. John Harley recommends a drachm of the fern ex- 
tract to be diluted with barley-water and injected into the bladder. 
Iodide of potassium may be used of the strength of fifteen or twenty 
grains to the fluid ounce. Dr. J. Wortabet speaks in favour of the in- 
ternal administration of oil of turpentine, and records a case in which 
a complete cure was effected by drachm doses of this remedy. 

Retention of urine is not very common in young children. It may, 
however, be induced by mechanical causes. Thus, some little boys have 
a very long prepuce, with a narrow opening, through which the urine is 
forced with difficulty. This extra-urethral stricture forms a great obstacle 
to the complete emptying of the bladder, and may be a cause of serious 
injury to the health. Cases are occasionally met with in which dilatation 
of the bladder, ureters, and pelves of the kidneys have been induced by 
such long-continued retention and pressure. Another common consequence 
of the straining efforts which usually accompany the attempt to evacuate 
the bladder is prolapsus ani. Ketention of urine may also result from 
the presence of a calculus, which, becoming impacted in the urethra, pre- 
vents the passage of water from the bladder. I have even known such 
an accident to lead to rupture of the membranous part of the urethra, 
and extravasation of the urine. Again, irritation of the rectum by worms 
may be a cause of spasmodic -retention of urine. Violent blows upon 
the lower part of the abdomen may produce a temporary paralysis of the 
bladder and retention. Lastly, in some cases of febrile disease, such as 
typhoid fever, we occasionally find distention of the bladder from atony 
of the muscular coat. 

Incontinence of urine, or enuresis, as it is called, is a much more familiar 
symptom in young children than retention. Involuntary passage of the 
water may occur in the night or in the day ; and sometimes the child is 
unable to control his bladder either by day or by night. This distressing 
infirmity is far from uncommon. It may date from birth, or may be ac- 
quired later. When acquired, its first occurrence has been attributed to 
fright ; but it is a popular impression that all nervous derangements are 
excited by some shock to the nervous system, and too much importance 
must not be attached to this explanation. In cases where it is not due to 
manifest weakness of mind or pure laziness of body, and where no disor- 
dered condition is present to which the incontinence can be attributed, we 
may sometimes, by careful examination, detect some external source of irri- 
tation which requires removal. Thus, the urine may be habitually too 
acid, and deposit ciystals of uric acid ; there may be phimosis, allowing 
of accumulation of irritating secretion beneath the prepuce ; the urethral 
orifice may be narrowed externally ; the prepuce may be wholly or in part 
adherent to the glans ; or again, great irritation may be excited in the 
neighbourhood by thread-worms in the rectum. In a sensitive child irri- 
tation at some distance from the bladder may act as the exciting cause. 
Thus, enuresis may be the consequence of chronic disease of the hip-joint, 
and may cease when, by rest and proper mechanical appliances, the irrita- 
tion of the joint has been subdued. Sometimes the most careful investi- 
gation fails to discover any such exciting cause. The incompetence is 
then attributed to general irritability of the nervous system, or to " spinal 
irritation." 



THE URINE — INCONTINENCE — ENURESIS. 749 

The mechanism of the phenomenon is well understood. Owing to 
causes which may or may not be capable of explanation, there is excessive 
irritability of the muscular fibres of the bladder. Under normal condi- 
tions the bladder is closed by the contraction of the sphincter vesicae, 
whose office it is to resist the action of the fibres forming the muscular 
coat. If necessary, the involuntary contraction of the sphincter can be re- 
inforced by the exercise of the will. In the more common form of incon- 
tinence, where the involuntary passage of urine takes place at night only, 
the irritability of the muscular coat is exaggerated, and the resistance of 
the sphincter is relatively deficient. There is no atony of the sphincter, 
but on account of the increased pressure against which it has to contend 
it requires to be strengthened by voluntary agency. During sleep the 
agency of the will is removed, and the sphincter can no longer effectually 
resist the action of the irritable muscular fibres, so that the contents of 
the bladder are discharged. In cases where, in addition to the abnormal 
excitability of the muscular coat there is a certain degree of atony of the 
sphincter, the patient has little control over his bladder even during the 
daytime. Micturition is frequent, and when the desire to pass water 
manifests itself, it can hardly be resisted even for a few seconds. 

This derangement has been classed amongst the neuroses, with epi- 
lepsy, chorea, and other similar affections. According to Trousseau, it is 
often found in families prone to epilepsy, and may thus be a hereditary 
failing. It cannot, however, be always attributed to a faulty condition of 
the nervous system. In many instances it appears rather to be due to the 
active reflex sensibility which is normal to the healthy child. These are 
the cases in which the enuresis is manifestly the consequence of some ex- 
ternal source of irritation, and ceases when this is removed. We know 
how promptly, in health, the nervous system of a child responds to reflex 
stimuli, and we constantly have occasion to observe the perturbation into 
which the whole system is thrown by the action of some external irritant. 
No doubt the class of cases in which the power of controlling the bladder 
returns "of itself," more or less suddenly, are cases of this kind. As the 
child grows older, the extreme sensitiveness of his nervous system to ex- 
ternal impressions becomes dulled. The only variety of enuresis which 
can be classed justly amongst the true nervous affections is that in which 
the incontinence is hereditary, or occurs in families subject to epilepsy or 
other form of neurotic disease, J or is apparently a consequence of nervous 
instability without any external cause being discovered to which the faulty 
action can be attributed. 

Enuresis, when acquired after infancy, is generally observed first be- 
tween the third and fourth years. It is seen as often amongst the stroug 
and robust children as amongst the thin and delicate ; but is, perhaps, 
more common in boys than in girls. The more obstinate forms of this in- 
firmity are, however, more common in the female sex, probably because 
in them the complaint is less often the consequence of external irritation. 
In ordinary cases the accident occurs only at night, and even then not 
every night. Often for a week or more the bed remains dry. Then it is 
wetted regularly for several nights in succession, and sometimes the acci- 
dent occurs on the same night several times. It is usually during the 
early hours, or later towards daybreak, that the child's bladder seems to 
be least under control ; and it is at these times that the incontinence is 

1 It must not be forgotten that nocturnal incontinence of urine may be the only 
sign of the occurrence of true epileptic attacks in the night. 



750 DISEASE IN" CHILDREN. 

usually manifested. After continuing for a variable time the infirmity may 
disappear without treatment. The periods of second dentition and of 
puberty are popularly supposed to be sometimes marked by this favoura- 
ble change. 

In the treatment of enuresis our first care should be to search for any 
source of external irritation. If this can be found, its removal forms the 
first step to a cure, and indeed the case may require no further treatment. 
Thus, the removal of an elongated prepuce ; the separation of adhesions 
between the prepuce and the glans ; the expulsions of thread- worms, or 
suitable medicines by which too great acidity of urine has been remedied — - 
all of these measures have been followed by immediate relief from this 
distressing complaint. Sometimes, however, such measures have to be 
supplemented by others, directed to lessen the abnormal irritability of 
the muscular coat of the bladder. In all such cases care should be taken 
that the child drinks little towards evening, and empties his bladder com- 
pletely before he goes to bed. Moreover, if the incontinence occur in 
the early hours of the night, the nurse should be directed to take up the 
child and see that his bladder is properly relieved before herself retiring 
to rest. 

Of medicines which diminish irritability, belladonna takes the first 
place ; but it is important to be aware that this remedy, to be effectual, 
must be given in full doses. Children have a very remarkable tolerance 
for belladonna, and will often take it in surprising quantities before any 
of the physiological effects of the drug can be produced. In obstinate 
cases of enuresis the medicine should be pushed so as to produce dilata- 
tion of the pupils with slight dryness of the throat. In children of four 
or five years of age it is best to begin with twenty-five or thirty drops of 
the tincture of belladonna given three times in the day, and to increase 
the dose by five drops every second or third day, of course watching the 
effect. Ergot is another remedy which is often very successful. For a 
child of the same age twenty drops of the liquid extract may be given 
several times in the day. Bromide of potassium, benzoic acid (dose, five 
to ten grains), and benzoate of ammonia, digitalis, borax, cantharides, 
camphor, and chloral, have all been recommended as sj^eeifics in this com- 
plaint. Sometimes a combination of several drugs seems to be more 
effectual than one given alone. I have lately cured a little girl, aged four 
years, who had resisted all other treatment, with the following draught 
given three times in the day : — 

r>. Tinct. bellad 3 j. 

Potas. bromidi gr. x. 

Inf. digitalis 3 ij. 

Aquam ad. § ss. 

M. Ft. haustus. 

When the incontinence continues in the day as well as at night, strych- 
nia should be combined with the sedative so as to give tone to the feeble 
sphincter. In these cases, too, cauterization of the neck of the bladder 
with a strong solution of nitrate of silver (3j.- 3 j. to the ounce of water), 
has been found successful. 

Besides drugs, other measures have been employed in obstinate cases. 
Thus, abstinence from animal food, including meat-broths, has been found 
to succeed in cases where drugs and other treatment had failed. In some 
country places in England a popular remedy consists in wrapping the feet 



THE URINE — ENURESIS — TREATMENT. 751 

of the patient at night in cloths wrung out of cold water. I have never 
used this remedy, but it is said to be an effectual one. 

Electricity has been lately employed with advantage in these cases. 
One electrode in the shape of a spinal disk, connected with the positive 
pole of the battery, is applied to the lumbar region of the spine. A second 
electrode is placed above the pubes or in the perinseum. A weak current 
is then passed for several minutes once a day. It is said that under this 
treatment immediate improvement is noticed, and that a complete cure 
follows within a fortnight. 



CHAPTER II. 

CHRONIC BRIGHT'S DISEASE. 

Bright's disease, both in the acute and chronic stage, is seen in the child. 
The acute form is, however, the more generally met with on account of 
the frequency with which scarlatina occurs in early life, and the tendency 
of this specific fever to be complicated by acute renal disease and dropsy. 

Causation. — It is no doubt to scarlet fever that the large proportion of 
cases of acute Bright's disease in the young child must be referred. Still, 
it is not very uncommon to meet with acute renal dropsy in children who 
are without any history of scarlatina, who show no signs of desquamation 
of the skin, and in whom no cause for the symptoms but recent exposure 
to cold can be detected. The practice of short-coating infants of a few 
months old, regardless of the state of the weather, which prevails in this 
country, is no doubt often answerable for this as for other catarrhal dis- 
orders in early life. A child of a few months old, who has been recently 
short-coated, is taken out on a cold damp day almost naked from his waist 
downwards ; for his scanty skirts afford little protection to the lower part 
of his body. A day or two afterwards he is noticed to be pale and puffy- 
looking about the face ; he vomits, and his belly and legs begin to swell. 
At the same time his urine is scanty, high-coloured, perhaps smoky, and 
throws down a precipitate of albumen on boiling. This is not a rare in- 
stance, but occurs sufficiently often to be a not unfamiliar experience to 
most medical practitioners. It has been suggested that there is a connec- 
tion between eczema and kidney disease in children ; and eczema of the 
genitals has been said to be often followed by fatal renal symptoms ; but 
I cannot corroborate this statement by my own experience. 

The form of Bright's disease met with during the first two or three 
years of life is generally the acute variety. Infants, however, as w r ell as 
older children, may suffer from the disease in a chronic form ; but no doubt 
this is in many cases a relic of a previous acute attack. Certain diseases may 
lay the foundation of chronic renal mischief, viz., scarlatina, measles, small- 
pox, scrofulous disease of bone and of other tissues causing prolonged 
suppuration, ague, diphtheria, and (in infants) intestinal catarrh. 

Either the contracted granular kidney (interstitial nephritis), the large 
fatty kidney (chronic parenchymatous nephritis), or the amyloid kidney 
may be met with in early life ; but the first is rare at this age, although it 
appears to be sometimes set up by obstruction to the escape of urine, either 
from impacted calculus or some other cause ; and the fibroid interstitial 
growth may then be profuse. 

The large fatty kidney is more commonly met with than the preceding. 
This lesion is usually the result of acute Bright's disease, and commonly 
dates from an attack of scarlatina. It may, however, be chronic from the 
first and arise as a consequence of long-standing suppuration. 

The amyloid kidney is far from rare. Children, especially those who 



CHRONIC BEIGHT'S DISEASE — MORBID ANATOMY. 753 

are subjects of the scrofulous cachexia, are very liable to suffer from pro- 
fuse purulent discharges. If the discharge is continued for a long time 
together, it will often lead to amyloid degeneration of organs in which fie 
kidneys as well as the liver and spleen are involved. 

Morbid Anatomy.— It is unnecessary in a special treatise, such as the 
present, to enter minutely into the pathological changes to be met with in 
the kidney in cases of chronic Bright's disease. These changes are the 
same in the child as they are in the adult, and are described at length in 
all the text-books. It may be sufficient to recall to the reader's memory 
the principal points connected with each of these three varieties. 

The contracted granular kidney is, as its name implies, considerably re- 
duced in size. Its capsule is thickened and adherent ; its surface is nodu- 
lar, and its colour a deep red. On section we find the cortex thin ; the 
medulla atrophied, and the substance dense. The essence of the disease 
consists in a great hyperplasia of the connective tissue of the organ. This 
fibroid overgrowth passes inwards from the surface along the course of the 
intertubular vessels, and involves more or less regularly the whole depth 
of the cortex. It thickens the Malpighian capsules, and compresses the 
capillary tufts and the convoluted tubes. The small arteries are thickened 
and their calibre reduced. As the increase of fibrous tissue is not evenly 
distributed, but is much greater in some spots than it is in others, the 
amount of injury to the kidney substance varies ; and while some tubes are 
much atrophied and shrunken, others escape almost entirely. The convolut- 
ed tubes are often denuded of their epithelial lining, and are sometimes seen 
under the microscope to be stuffed with fatty debris or with hyaline casts. 
In some places the denuded tubules dilate here and there into cysts ; in 
other places they atrophy and may be converted into mere threads. The 
straight tubes in the pyramids are comparatively little altered. The 
shrinking of the kidney and its granular appearance are late changes, and 
are due to the contraction of the new fibroid material. 

In the large white fatty kidney it is the tubular structure which is prin- 
cipally involved— especially the convoluted tubes in the cortex. The kid- 
ney is larger than natural, and its capsule can be readily detached. The 
cortical part of the kidney, to swelling of which the increase in size is due, 
is perfectly smooth on the surface and pale in colour. No ramifying ca- 
pillaries are to be seen, but here and there red specks from extravasation of 
blood dot the ansemic surface. 

On section the cortex has the same pallid tint, and contrasts curiously 
with the cones of the pyramids which still retain their healthy colour. By 
the microscope the convoluted tubes are seen distended to twice their 
natural size ; and their epithelial lining is swollen and granular looking. 
The tubes often contain granular debris and fibrinous exudation, and, 
sometimes, extravasated blood from a ruptured Malpighian body. 

After a time the epithelial cells in the tubes become disintegrated 
and are removed, and sometimes increase of the interstitial connective tis- 
sue takes place as in the preceding variety. The kidney then shrinks and 
may become granular on the surface, but still continues very pale in 
colour. 

Amyloid disease in the kidney is usually associated with the same de- 
generation of the liver and spleen. If the degeneration is marked, the or- 
gan is increased in size and has a waxy, pale, and slightly translucent ap- 
pearance. The amyloid change begins, as a rule, in the vessels of the 
Malpighian tufts, but soon spreads from these to the vessels (both afferent 
and efferent), the vascular plexuses (both intertubular and interlobular), 
48 



754 DISEASE IN CHILDREN". 

and the urinary tubules. This condition is often combined with other 
forms of renal degeneration. 

Symptoms. — The symptoms of acute Bright' s disease have been already 
considered in the chapter on Scarlatina. 

The chronic disease in its earlier stages, and until it gives rise to dropsy, 
is accompanied by few symptoms, and, indeed, is probably often over- 
looked. The child is pale, dull, and listless. He complains of his head, 
and is capricious in his eating. Sometimes he passes large quantities of 
water, which — especially if the disease be of the granular variety — may be 
of normal density, and contain no albumen. Even when dropsy occurs, 
albuminuria may be absent or trifling. 

A little boy, aged one year and ten months, with sixteen teeth, began 
gradually to get poorly. He grew pale, seemed heavy and sleepy, and 
vomited often after his meals. After this state of things had continued 
for a month his face became puffy, his eyelids swelled, and general oedema 
appeared over the body and limbs. "When taken into the East London 
Children's Hospital, no disease of any organ could be discovered ; the liver 
and spleen were of natural size ; the heart was healthy, and the tempera- 
ture was normal. There was no sign of peeling of the skin. For some 
days no urine could be collected, for the quantity was scanty, and the 
child passed it all in his cot. At last some was obtained, but no albumen 
was discovered, nor could any casts of tubes be seen. Purges and dia- 
phoretics soon dispersed the oedema, and the child then took iron and 
cod-liver oil. The sickness continued for some weeks after the oedema 
had disappeared. The urine was examined several times, but no albumen 
was ever found. 

The dropsy in this case was not the result of anaemia and weakness, for 
the child was not at all emaciated, and his mucous membranes were fairly 
red. The oedema had all the characters of kidney dropsy. It began in 
the face, and was distributed very generally over the body. A similar 
form of dropsy without albuminuria or casts is sometimes found as a sequel 
of scarlet fever. 

In some cases Bright's disease appears to be quite latent until oedema 
occurs. 

A little boy, aged twenty-one months, with twelve teeth, came into the 
hospital, under my care, with slight dropsy which had lasted for a week. 
The child had never had scarlatina or measles ; and had been a fairly 
healthy boy, although for some weeks his bowels had been relaxed, and 
the discharges offensive. He had suffered, shortly before admission, from 
ulceration of the mouth, which, however, had been soon recovered from. 
He coughed, and his appetite was poor. 

When the child was first seen, the oedema, although slight, was gen- 
eral. The urine was scanty and alkaline, and contained one-sixteenth of 
albumen. There was a deposit of triple phosphate crystals, with many 
large and small hyaline casts, and some granular casts. The temperature 
at first was normal, but after a few days rose to 101.4° ; the child began 
to cough ; he was then violently convulsed, and died a few hours after- 
wards. 

On examination of the body the lower part of the right lung was found 
to be consolidated. The left kidney was absent. The right measured 
three inches in length by two and three-quarters in breadth. The capsule 
was adherent, and on removing it small portions of renal substance were 
torn away with it. The surface of the organ was very granular and irreg- 
ular. On section the tint was paler than natural ; the pyramids were less 



CHRONIC BRIGHT' S DISEASE— SYMPTOMS. 755 

red than in the healthy subject, and the cortex was thinned. The whol- 
kidney felt very dense, and its substance seemed unusually tough. Un- 
fortunately, the organ was not examined microscopically, but there can be 
little doubt that this was a case of granular kidney, and that it was of 
some standing, although in so young a child. 

Sometimes the only sign of the chronic disease may be the marked 
pallor of the complexion, with frequent attacks of headache and vomitino- 
lasting tor several days, or a week or more at a time. Sometimes, as fn 
the adult the sight becomes affected from albuminous retinitis. Such 
cases, without a careful examination of the urine, may be mistaken for 
cerebral tumour. Indeed, a history of frequent attacks of headache and 
vertigo, accompanied by vomiting, and of gradual failure of the sight is 
very suspicious of a tumour of the brain. In all such cases, therefore it 
is very important to make a careful examination of the water for albumen 
and to search the deposit frequently for casts of tubes. The skin is gen- 
erally dry and rough, and is often markedly inelastic, so that when pinched 
up into folds it remains wrinkled, and does not smooth out quickly, as a 
healthy skin would do. This is especially the case in infants and the 
younger children Purpura is sometimes found to be an accompaniment 
of the renal mischief ; but whether it is excited by the nephritis, or, as 
l>r. tree suggests, arises with it as a consequence of some bodily condition 
common to both, is uncertain. Purpuric patches may be seen on the 
skin, and blood may be passed with the urine and stools. 

Usually, acute exacerbations occur from time to time. These mostly 
follow a chill, and are accompanied by scanty secretion of urine, puffiness 
of the face, and oedema of the limbs. The water is then albuminous and 
maybe smoky, or even red, from admixture with blood. The headache 
is often severe, vomiting may be distressing, the dropsy may be marked 
and convulsions may occur, with drowsiness or coma. Sometimes the 
attack is complicated with pericarditis or pleurisy, as it is in the adult 
When the acute symptoms subside, the amount of albumen gradually 
diminishes, and after a time may quite disappear from the urine. There 
may be then little left to show that the kidneys are not healthy but re- 
peated examinations of the urine will perhaps disclose a slight deposit 
with fragments of granular or hyaline casts. 

In cases of acute renal dropsy, it is common enough to hear that the 
child had had scarlatina some months or years previously, followed by 
dropsy ; that he had completely recovered to all appearance ; but that lately 
having been exposed to cold, he had begun to vomit and the oedema had 
reappeared. In such a case it is reasonable to conclude that the restora- 
tion of the kidneys was not so complete as had been supposed. Some- 
times the acute exacerbation is preceded by pallor, wasting, vomitino- gen- 
eral weariness, and a look of ill-health. The child passes water °much 
more frequently than natural in the day, and at night may wet his bed. 

A boy, aged fourteen, was in the East London Children's Hospital 
under the care of my colleague, Dr. Donkin. The patient had had mea- 
sles and scarlatina. He was said to be very duU at his lessons. His se- 
cretion of urine was large, and he seemed to have a difficulty in holding 
it. A month before his admission the boy had had a rash over the body 
which had lasted a fortnight. He had then begun to vomit his food, 
complained of pain all over, looked pallid and weakly, and was manifestly 
losing flesh. J 

When admitted, he was pale and thin ; seemed very fretful, and looked 
ill. His temperature was normal. His urine was acid, had a specific 



756 DISEASE IN CHILDREN. 

gravity of 1.015, and contained no albumen or sugar. The boy coughed 
a little, but nothing positive was noted about his chest. There was no 
sign of peeling of the skin. 

After being in the hospital for about three weeks, during which time 
he had decidedly improved and had gained flesh, the lad was allowed to go 
out into the garden. The same evening his face looked puffy, and his legs 
were found to pit on pressure. His temperature that night was normal. 
On the following day the oedema was marked. He vomited several times ; 
complained of severe headache, and seemed very stupid and stubborn. 
His temperature rose that evening to 100°. His water was smoky, con- 
tained a sixth of albumen, and had a flocculent deposit which showed 
under the microscope many granular casts. On the third day his tem- 
perature was 101.8° both morning and evening, and he had a series of con- 
vulsive fits, followed by drowsiness which lasted for twenty-four hours. 
His temperature then became normal again, and the oedema began to de- 
cline. His water was discoloured with blood for several days, and the al- 
bumen and casts only slowly disappeared ; but before the boy's discharge, 
his urine, except for a slight haziness with the cold nitric acid test, had 
again become normal. 

In this case the history and the previous symptoms, as well as the 
rapidity with which the renal phenomena followed the chill, pointed to 
some chronic affection of the kidneys, although no albumen was found in 
the urine on the lad's admission into the hospital. Perhaps in many of 
these cases careful and repeated examination of the water would be more 
successful in finding albumen. A great deal depends, too, on the way in 
which the examination is conducted. Boiling the urine and afterwards 
adding a few drops of nitric acid is a very coarse test ; and if the propor- 
tion of albumen is small, it may easily escape detection by this means. A 
far more delicate test is that of floating cold urine from a pipette upon the 
surface of strong nitric acid placed in the bottom of a test-tube. Albumen 
should never be excluded until the urine has been tested by this process, 
and allowed to stand for a quarter of an hour in order to give the light, 
cloudy disk of albumen time to form upon the top of the acid. Still, it 
cannot be denied that, however carefully the examination may have been 
conducted, it will often be impossible to discover the presence of even a 
trace of albumen between the attacks of acute disease. The child, how- 
ever, is not .well. He often remains pale and thin, loses all appetite, and 
is nervous and excitable. His dislike to eating is a source of great anx- 
iety to his parents, and, indeed, it is often most difficult to persuade him 
to take even a minimum quantity of food. 

The water may be secreted in fair amount, often, indeed, is copious 
but its specific gravity is low. It is usually very acid, and sometimes uric 
acid sand is seen at the bottom of the chamber-pan. Perhaps on this ao 
count there is often a difficulty in holding the water, especially at night 
There can, be little doubt that, although giving rise to no very characteris 
tic symptoms, the kidneys are not healthy, and that their depurative func 
tions are imperfectly performed. 

A case which I saw some time ago, in consultation with Mr. E. Stanley 
Smith, affords a good example of the insidious progress of granular kid 
ney disease in the child. 

A little boy, aged nine years, of excitable, nervous temperament, in 
heriting a tendency to epilepsy on his father's side, and to phthisis on his 
mother's, was said to have been poorly for eighteen months. His indis- 
position had begun with an attack of "fever" in which the temperatur 



DISEASE — SYMPTOMS. 757 

rose every night to 102° or 103° ; he had severe headache, and was at 
times slightly delirious. He was ill for a week. Since that time he had had 
similar attacks, but milder in character. He was said often to look pasty 
and sallow in the face, and to seem languid and inclined to mope, although 
when pretty well in health he was lively and active, and his spirits were 
high. When poorly, his urine would contain a trace of albumen ; it was 
always very acid, and often contained large quantities of uric acid sand. 
No casts were ever seen at that time. The boy was wasting slowly, al- 
though his appetite was good. He slept badly, and was always restless at 
night. His bowels were usually costive, and after an aperient he passed 
much mucus. He stammered at times, and the muscles of his face would 
often twitch. The specimen of his urine shown to me was very acid and 
of specific gravity 1.024. It contained no trace of albumen ; but there was 
a copious deposit of uric acid sand. After I had seen the boy he did not 
improve. The albumen became more frequent, and granular casts and 
blood-corpuscles began to be discovered. On one occasion, a hyaline cast 
was seen. There was never any trace of oedema, and his heart and pulse 
were normal. 

In this case the feverish attacks were no doubt attacks of acute gastric 
catarrh. Apart from this symptom, which may have been only an acci- 
dental feature in the case, and had probably no other influence than that 
of aggravating the tendency to flatulence and acidity, there can be little 
doubt that the boy was suffering from granular kidney. It seems prob- 
able that there is a connection between the passage of red sand and the 
kidney degeneration, for I have noticed the association in other instances. 
Certainly, in a case where a child habitually passes large quantities of uric 
acid crystals, I should be disposed to fear the occurrence of Bright's 
disease ; and the occasional presence of a trace of albumen would add 
strength to my apprehensions. 

The after-course of this boy's case is interesting. He was sent to the 
south of France, and passed a considerable time at Cannes. Dr. G. C. 
Bright, under whose care the boy was placed, informs me that on arriving 
at Cannes the urine contained one-eighth of albumen, and that its sediment 
showed numerous granular casts and much renal epithelium. After a stay 
of nine months the water had ceased to contain albumen or casts, although 
there was still an occasional deposit of uric acid sand. Its density was 
habitually 1.025. 

In this boy there was no hypertrophy of the heart ; and no abnormal 
tension of the pulse was ever noticed. Although the albumen ceased for a 
time to be present in the urine, it is impossible to suppose that all structural 
lesion of the kidneys had disappeared. This is no doubt another instance of 
renal disease without albuminuria, or rather, with intermittent albuminuria, 
for that albumen and casts will eventually reappear can scarcely be doubted. 
It is curious that a sister of the patient suffered from similar symptoms. 

When the kidney is the seat of amyloid degeneration there is no neces- 
sary albuminuria, and even increased secretion of urine is not an invariable 
symptom. Dr. M. Litten has published the details of four cases which place 
the truth of this statement beyond a doubt. In a case which was under my 
own care — a little girl seven years of age — general oedema had been present 
for two years, succeeding to an attack of scarlatina. The child suffered 
from angular curvature of the spine of some standing. Her liver and spleen 
were much enlarged, and felt very dense and resisting. Enlarged mesen- 
teric glands could be detected in the abdomen on deep pressure. The aver- 
age quantity of water passed in the twenty-four hours was twelve ounces. 



758 DISEASE IN CIIILDKEN. 

It had a copious deposit of lithates. There was never any albumen, nor 
could any casts be discovered under the microscope. Its density varied 
from 1.020 to 1.025. 

In this case, where the liver and spleen were evidently the seat of amy- 
loid degeneration with probable enlargement of the same kind in the mesen- 
teric glands, it is difficult to suppose that the kidneys had entirely escaped 
any participation in the disease. Probably only an early stage of the degen- 
eration is characterised by absence of albuminuria and a scanty secretion 
of urine. As the disease becomes more advariced, the quantity of water 
secreted is more copious ; it contains albumen — at first in small quantities, 
afterwards in considerable amount, and the specific gravity of the fluid is 
high. Renal epithelium with hyaline, granular, and often fatty casts, may 
be seen by the microscope in the deposit. 

There is a form of renal disease from which children of various ages are 
prone to suffer, which appears to be in many cases a temporary ailment, but 
which produces very definite symptoms. The disorder is indicated by pal- 
lor, weakness, wasting, constipation, sometimes by sickness, and in every 
case by a remarkable absence of the natural elasticity of the skin. This loss 
of elasticity is a very characteristic symptom. When the skin of the abdomen 
is pinched up, it remains wrinkled, or only slowly recovers its smoothness. 
On examining the water no albumen is found, but the quantity is small and 
its specific gravity is low. Evidently sufficient solids are not discharged by 
the kidneys ; and the retention of effete matters in the system, owing to this 
renal inadequacy, is apparently the cause of the symptoms. A case has 
been already referred to in the chapter on enteric fever, in which a child 
convalescent from that disease passed for many days no more than eight or 
ten ounces of urine in the twenty-four hours, with a specific gravity of 1.015. 
He was excessively feeble, stupid, and lethargic ; his skin was markedly 
inelastic ; and it was only after the secretion of water had increased, and its 
density had risen, that his physical and mental weakness passed off, and the 
normal elasticity of his skin was restored. It Avas calculated that this boy 
secreted by the kidneys, in the twenty-four hours, no more than two and 
three-quarter grains of solid matters for every pound of his weight — a 
quantity which is of course considerably below the average amount. 

The quantity of urea passed daily in childhood is proportionately greater 
than it is in adult life. In the East London Children's Hospital I caused 
the urine of thirteen selected cases, in which kidney disease could be ex- 
cluded, to be collected for the twenty-four hours ; and calculating roughly 
from the specific gravity, it appeared that the average quantity of solid mat- 
ters passed from the kidneys in this time was five grains for every pound of 
the child's weight. The ages of the children were between four and ten 
years. In the adult the daily quantity has been estimated by Dr. Parkes 
to be three and a half grains per pound weight. My experiment was of 
course a rough one, making no pretensions to mathematical accuracy; 
but the conclusion arrived at was, no doubt, sufficiently near the truth to 
be useful as a guide in practice. 

I believe quite young children sometimes suffer from a temporary de- 
ficiency in the secretion of urea, although, as it is impossible to collect the 
whole quantity of urine passed, I can bring forward no positive evidence 
in support of this statement. Some time ago I saw a male infant seven 
weeks old, who was brought up at the breast of a very healthy mother. 
He had been perfectly well for the first four weeks after his birth. He 
had then begun to vomit sour fluid and curd, and at the same time his 
bowels had become obstinately confined. This state of things had con- 



CHRONIC BRIGHT' S DISEASE— SYMPTOMS— DIAGNOSIS. 759 

tirmed for three weeks, the infant becoming thinner, and his bowels only 
acting after an aperient or enema. On the morning of the visit he had 
just been relieved after five days' constipation. The child was thin but did 
not look ill. No sign of disease could be observed about any part of his 
body, and the belly was not retracted. The skin was excessively inelastic. 
It lay on the abdomen in loose wrinkles, and when pinched up, the folds 
remained exactly as they were left without smoothing out. No urine could 
be obtained for examination. An aperient powder was given, and small 
doses of the infusion of senna with glycerine were ordered three times a 
day. After two months the elasticity of the skin had partially returned 
and eventually it was perfectly restored. The return of elasticity in the 
skm was accompanied by progressive improvement in the condition of 
the child. The vomiting ceased soon after treatment was begun ; but the 
costive state of the bowels remained a trouble for a considerable time. 

The above case represents a form of derangement which is sometimes 
met with in the infant. It is not an ordinary case of gastric catarrh, such 
as is common in early infancy, for in this disorder the elasticity of the 
skin is in no way interfered with. Nausea and vomiting, constipation, a 
dry, inelastic skm, and slight albuminuria, form a combination of symptoms 
constantly met with in cases of deficient renal secretion in children whose 
water can be tested, and also in adults, according to Sir Andrew Clark. It 
seems, therefore, at any rate possible that diminished functional activity of 
the kidneys may produce similar symptoms in the infant. Kjellberg has 
observed a frequent connection between intestinal catarrh and parenchy- 
matous inflammation of the kidney in the young child, and mentions as 
one of the characteristic symptoms of the kidney complication a dry, 
tough skin without elasticity. In every case, therefore, where we find this 
condition of the skin in a young subject, we should examine very carefully 
for signs of renal disease. 

Diagnosis. — In examining for albumen a specimen of the urine passed 
after the first meal in the day should be taken, and the fluid should be 
afterwards set aside in a conical glass in order that solid particles, if any, 
may subside The deposit should be taken up carefully with a pipette,' 
and placed in a shallow cell made by cementing a thin ring of glass on to 
the ordinary microscope slide. This, covered with a thin glass, should be 
carefully searched for casts of tubes. 

The complete absence of albuminuria and casts is no sufficient indica- 
tion that the kidneys are perfectly healthy. It seems probable, from the 
cases which have been narrated, that a certain amount of disease may 
exist in the kidneys although the urine presents the characters of 'health ; 
and it is now an established fact that considerable amyloid degeneration 
may exist in the organ without its presence being betrayed by any 
abnormal condition of the urinary secretion. In all cases where renal 
disease is suspected, although no albuminuria can be discovered, it is well 
to cause the whole amount of water passed in the twenty-four hours to be 
collected. A calculation can then be made from the specific gravity of the 
fluid, by means of Professor Haughton's tables, 1 which will give a rough 
estimate of the quantity of urea being excreted in the course of the day 
and night. If at the same time we ascertain the weight of the child, the 
amount of solid matters passed for each pound of his weight can be easily 
calculated. A healthy child should pass daily between five and six grains 
of urea per pound of his weight. 

1 Given in the Medical Times and Gazette for October 27, 1864. 



760 DISEASE IN CHILDREN. 

If albuminuria and casts can be detected, it is not always easy to 
decide upon the nature of the kidney lesion. The presence of amyloid 
degeneration of the liver and spleen renders the same condition of the 
kidney very probable. A chronic form of Bright's disease succeeding to 
an acute attack, such as an attack of scarlatinous nephritis, is usually due 
to the fatty kidney (chronic parenchymatous nephritis) ; but this form of 
Bright's disease may also, like the contracted granular kidney, begin in- 
sidiously. If albuminuria and casts are present without dropsy, the kidney 
is probably granular. 

The constant passage of red sand from the kidneys is to be regarded 
with anxiety, for in such cases Bright's disease may be developed after a 
time, as in the case of the child before referred to. 

Prognosis. — When Bright's disease is established in the child, i.e., 
when albumen and casts are constantly present, the prognosis is very un- 
favourable ; for such a condition, if it do not destroy life unassisted, must 
greatly increase the danger of any intercurrent malady. Such children, if 
attacked by pneumonia or pleurisy, are very likely to die. In the case of 
amyloid kidney the prognosis is, perhaps, less unfavourable than in the 
other forms of Bright's disease ; for it seems possible that, if the chronic 
suppurative process which has excited the structural change can be re- 
moved by operation or otherwise, all the symptoms of kidney derangement 
may disappear. That such a happy termination to the illness is possible, 
is proved by a case published by Mr. Barwell, in which, after the removal 
of a scrofulous joint, albuminuria and casts ceased after a time to be found 
in the urine, and the child grew up into a strong, healthy woman. From 
this case we may learn that the existence of amyloid disease of the kidneys 
is no bar to the successful issue of operative procedures ; but that on the 
contrary, surgical interference in such cases is urgently called for. 

Mere renal inadequacy, without albuminuria or history of acute Bright's 
disease, is probably in most cases a merely temporary condition which, 
under suitable treatment, may be rapidly recovered from. But if a child 
habitually pass large quantities of uric acid sand, or if he have more than 
one attack of acute Bright's disease, even although the urine have been 
normal in the interval, and return to a healthy state after the symptoms 
have passed away, we should regard the possibility of his ultimately devel- 
oping manifest disease of the kidneys as one not to be entirely excluded 
from consideration. 

Treatment. — In cases where we find deficient secretion of urea, without 
albuminuria or signs of organic renal disease, we should take care to un- 
load the bowels by free purgatives, unless, as in the case before referred 
to, the child be just convalescent from typhoid fever. In ordinary cases 
gray powder and jalapine may be given in doses suitable to the age of the 
child. He should be made to drink freely of some harmless fluid, and 
thin barley-water sweetened and flavoured with vanilla is very useful as a 
mucilaginous diuretic. The aperient should be repeated as often as seems 
desirable to ensure complete relief to the bowels ; and in addition the pa- 
tient may take a mixture containing citrate of potash with tincture of nux 
vomica, or a few drops of tincture of rhubarb. The child should not be 
allowed too much animal food. Fish is better for him than butcher's 
meat, and he should take plenty of milk and green vegetables. If broth 
be allowed it must be perfectly fresh, and not be made from " stock." If 
there be ansemia in these cases, iron can be given after a time. 

If a child be the subject of undoubted renal disease, it is of the utmost 
importance to attend to the working of functions the impaired action of 



CHRONIC BRIGHT' S DISEASE — TREATMENT. 761 

which will increase the labour of the kidneys. The skin should be en- 
couraged to act by a daily tepid bath, by warm clothing, and by careful 
avoidance of the causes of chill. The patient should be dressed from head 
to foot in flannel or other warm woollen material, and should take regular 
exercise in the open air. The bowels, if inclined to be costive, should be 
kept relieved by aperients ; and small doses of senna, or podophylline and 
belladonna, or a nightly dose of Hunyadi Janos water, as recommended in 
the chapter on constipation, are very useful. The patient should eat 
sparingly of flesh meat ; but milk and fish are suitable, and a due propor- 
tion of farinaceous and vegetable matters should be included in his diet. 
If the amount of albumen is great, it may be advisable to put the child 
for a time upon a diet consisting merely of milk and bread. Certainly in 
such cases animal food should be taken with caution, and should not be 
allowed every day. 

Climate is a matter of very great importance in cases of chronic renal 
disease. If possible, the child should be removed for the winter to a 
neighbourhood where the air is fairly warm and dry. Here he can pass 
his time out of doors without risk of chill, and the beneficial influence of 
such a change is often very remarkable. The albumen and casts may 
quite disappear from the urine, and for the time, at least, the health may 
seem to be completely restored. 

Of medicines, iron is the best remedy, and the perchloride the best 
preparation. This salt has a distinctly diuretic action, especially if well 
diluted with water. Its influence in promoting the renal secretion is in- 
creased by the addition of dilute acetic acid and solution of acetate of 
ammonia, as suggested by the late Dr. Basham (see page 730). The 
draught may be sweetened by glycerine or by a few drops of spirits of 
chloroform. 

If an attack of acute Bright's disease come on, with elevation of tem- 
perature, oedema, and head symptoms, relief may be speedily obtained in 
the majority of cases by free purgation and packing in a blanket bath, as 
recommended in cases of scarlatinous nephritis (see page 46). The in- 
fluence of energetic purgation, too, is most striking ; nothing relieves head 
symptoms so quickly as a good sweeping aperient. A useful form is the 
combination of compound jalap powder with compound scammony pow- 
der. Enough should be given to produce four or five copious evacuations. 
Elaterium is too uncertain in its action to be suitable for children. 

If the albuminuria persist after an attack of the acute disease, iron 
should be given directly the temperature becomes normal. The drug may 
be usefully combined with strychnia and arsenic. A child of eight years 
old may take three times a day twenty drops of the liq. ferri perchloridi 
with two of liq. strychnise and four of liq. arsenicalis in a large wineglass- 
ful of water sweetened with glycerine. This medicine should be given 
directly after food, lest it cause nausea. Gallic acid has been recommended, 
but on account of its tendency to constipate often seems to do more harm 
than good. The first necessity in these cases is to promote free excretion 
from the bowels. If this function be interfered with, no medicine can be 
of much value. On this account iron often seems to act better if given in 
the form of the sulphate with sulphate of magnesia and dilute sulphuric 
acid ; but the other form is equally, if not more, serviceable, if care be 
taken to keep the bowels free. In obstinate cases fuschine (the chloro- 
hydrate of rosaniline) is said to hasten the disappearance of the albumen 
after an acute attack. This drug may be given to a child in doses of from 
two to five grains. It tinges the urine of a reddish colour. Recently, 



762 DISEASE IN CHILDREN. 

chloral hydrate has been given with the same object. It can be prescribed 
to a child of five years of age in doses of three or four grains three times a 
day. 

A fatal ending in uncomplicated cases of chronic Bright's disease from 
exhaustion and dropsy must be rare in the child. I cannot remember 
having met with such a case except in connection with amyloid disease, 
and there the general distribution of the degeneration furnishes other rea- 
sons for the condition of the patient. Chronic kidney disease is usually 
fatal in young subjects through the occurrence of some inflammatory com- 
plication. Pleurisy and pneumonia in such cases are excessively danger- 
ous. They must be treated with stimulants and counter-irritation. The 
chest and back should be repeatedly dry-cupped ; the bowels should be 
freely acted upon, and the strength of the patient must be supported by 
suitable quantities of unsweetened gin. 

If the dropsy in any case be copious, it must be treated as recommended 
under the head of Scarlatinous Nephritis (see page 46). Pilocarpine is 
sometimes useful in these cases. Occasionally it may be necessary to 
puncture the legs with Dr. Southey's trocars. 



CHAPTER III. 

CALCULUS OF THE KIDNEY. 

The occasional passage of red sand from the bladder in childhood is not 
an uncommon occurrence. As a rule, little pathological significance is to 
be attached to it. Uric acid is very liable to be formed if food is taken 
largely in excess of the requirements of the system. It is not even neces- 
sary that the food be nitrogenous to produce this result ; for as Dr. Grarrod 
has observed, it is a mistake to suppose that an animal diet must tend 
more to the formation of uric acid than a vegetable one. It must be re- 
membered, however, that the presence in the urine of a deposit of lithic 
acid or its salts is no proof that any excess of the acid is formed and se- 
creted. The increase is often only apparent. When the urine is scanty 
from deficiency of water, the uric acid may appear to be in excess. Again, 
great acidity of urine may cause a deposit of uric acid. The neutral 
lithates are more soluble than the acid lithates, and these than uric acid. 
Therefore, if the urine is full of neutral salts, any cause which will remove 
a part or the whole of the base will throw down a precipitate. The addi- 
tion of acid will do this. Thus, if very acid urine be secreted into the 
bladder when this already contains a neutral or alkaline urine, the acid 
abstracts the base from the neutral salts and a deposit is formed at once. 

The uric acid appears in the urine in the form of crystalline grains, or, 
if very abundant, as a red sandy deposit. In infants and young children 
there appears to be a special tendency to uric acid deposits ; and these 
may be thrown down in the kidney itself before the urine has passed into 
the bladder. The so-called uric acid infarctions of the kidney, forming 
yellowish red streaks running in the direction of the pyramids, may be 
found after death in the youngest infants — in them, indeed, more fre- 
quently than in older children. These infarctions consist of amorphous 
urate of ammonia mixed with crystals of uric acid, and occupy the straight 
tubes of the pyramids. They do not, any more than the sandy deposits 
in the urine, indicate the existence of kidney disease. They are due to ex- 
cessive feeding, or, in young babies, to the increased metamorphosis of 
tissue elements which must take place after birth in consequence of the 
newly-inaugurated processes of digestion, respiration, and generation of 
heat. 

A deposit of crystals of uric acid may be formed at any part of the 
urinary apparatus. The urinary tubules often contain such collections. 
A particle of crystallised uric acid is deposited in the cortical part of the 
gland. It may remain in this spot, or may pass further down the urinary 
apparatus into the straight tubes or the pelvis of the kidney. In either 
case it is apt to become enlarged by successive additions to the original 
nucleus. Great irritation is often caused by the passage of these frag- 
ments, and even minute crystalline particles, if with sharp angles, may so 
scratch and wound the delicate membrane lining the fine tubules of the 



764 DISEASE IN CHILDREN. 

kidney and calices of the pyramids, as to be a cause of haemorrhage. In 
spite, however, of the frequency of sandy deposits, the urine in childhood 
does not, as often as might be expected, contain an admixture of blood. 
At least, an intimate blending of the blood with the urine, such as is known 
to be characteristic of renal hemorrhage, is in the child comparatively 
rare. 

Besides uric acid, oxalate of lime concretions are not uncommon in 
children. These are dependent upon the same causes as the preceding. 
According to Schenck, uric acid is converted by oxidation into oxaluric 
acid, and this is readily decomposed by both acids and alkalies, splitting up 
into oxalic acid and urea. The oxalic acid at once combines with the base 
of any lime salt which may be present, and is precipitated as the insoluble 
oxalate of lime. This process may take place in any part of the urinary 
passages, and if crystals of oxalate of lime are found in warm urine before 
the fluid has had time to cool, it may be inferred that they have been 
formed inside the bod} r , and we should think of the possibility of calculus. 

Besides uric acid and oxalate of lime concretions, small calculi of the 
urates of ammonia and soda may be formed. Often the concretions are 
compound, and contain a nucleus of uric acid round which oxalate of lime 
or urate of ammonia has been deposited. If the concretion be encrusted 
with phosphates, it is a sign that irritation has been set up in the bladder 
or pelvis of the kidney. 

Causation. — Some children have a greater tendency than others to the 
deposition of uric acid in the urinary passages. This tendency often runs 
in families, and is then commonly associated with the gouty constitution. 
The form of scrofula which is connected with a stout, heavy build, and 
much flabbiness of flesh, is also said to be distinguished by a similar ten- 
dency. In both of these cases there is no doubt an inclination to gastric 
disturbances and the generation of acid in the stomach. The actual deposi- 
tion of uric acid crystals in the form of sand and gravel is apt to be excited 
by excessive or unwholesome diet — especially of indulgence in the more 
fermentable articles of food. Thus, large quantities of farinaceous sub- 
stances, particularly where the starch is imperfectly cooked, and of fruit 
or sweets, may give rise to the formation of acid in the digestive organs. 
Too close confinement to the house, especially in cold damp weather, may 
in some subjects load the urine with uric acid or its compounds. Indeed, 
any influence which interferes with the assimilative processes, such as fear, 
grief, and other depressing passions of the mind, over-fatigue of the body, 
temporary febrile ailments — all these causes may determine a precipita- 
tion of uric acid in the urinary passages. According to Dr. Garrod, con- 
centration of the urine from deficiency in the amount of water excreted by 
the kidneys is a common cause of gravel in early life. In these cases the 
habitual passage of red sand is compatible with every evidence of good 
health. Amongst other cases he refers to that of a boy aged five and a 
half years, whose urine from day to day contained either uric acid crys- 
tals or deposited a copious red sediment almost immediately after it was 
voided. The whole quantity of urine passed in the twenty-four hours was 
only sixteen ounces, with a specific gravity of 1.031. Directly the child 
was made to take more fluid, so as to increase the quantity of water passed 
from the kidneys, uric acid ceased to be discoverable in the secretion. 

Symptoms. — The passage of the ordinary lithates is no more a cause of 
irritation in the young child than it is in the adult. A baby may pass 
water thick and milky from the presence of urates without showing that 
he is sensible of any unusual sensation while voiding the contents of his 



CALCULUS OF THE KIDNEY — SYMPTOMS. 765 

bladder. When, however, free uric acid is discharged with the urine, we 
usually notice signs of discomfort. "Water is passed more frequently and 
in smaller quantities. The child screams and strains during its passage, 
and, if old enough, complains of pain in the urethra. In these cases we 
shall often find red gritty matter on the infant's diaper, or red sand at the 
bottom of the chamber-pan. Sometimes, this irritation is a cause of wet- 
ting the bed at night, and therefore the water should always be examined 
for uric acid crystals in cases of nocturnal incontinence of urine. 

While still in the kidney these concretions may give rise to few or even 
no symptoms. Sometimes the only sign of their presence is a more or 
less copious admixture of blood with the urinary water. If the concre- 
tions are of some size, the haemorrhage may be accompanied by attacks of 
pain in the kidney. Hsematuria in children, especially in infants, is usually 
to be attributed to this cause. In the case of infants a stain of bright 
blood is noticed on the wet diaper. In older children the blood is inti- 
mately blended with the urine, and the mixture may have a deep red colour 
if the haemorrhage be copious. The urine is acid, deposits albumen on 
boiling, and often crystals of uric acid can be discovered with the abun- 
dant blood-corpuscles under the microscope. 

A little girl, aged four years, the ninth child of healthy parents, was 
admitted into the East London Children's Hospital. No history of gout 
could be discovered in the family. Of the other children, four had died, 
one from whooping-cough, the others of brain disease, nature unknown. 
The patient herself had always been a healthy child, with the exception of 
an attack of varicella in infancy, until twelve months before admission. 
At that time the mother had begun to notice that the child's water con- 
tained blood. At first this had only occurred about once a week ; but the 
frequency of the haemorrhage had gradually increased, and during the 
previous fortnight blood had been passed every day. The morning urine, 
passed after the night's rest, had, however, been always uncoloured until a 
week before admission ; since that time the passage of blood had been 
continuous. 

At first the mother had noticed no other symptoms, but after the 
haemorrhage had continued for several months, the patient had begun to 
complain of pain in the left side and back, at first only occasionally, but 
latterly several times in the day. The child cried bitterly, and attempted 
to relieve her distress by bending her body backwards across her mother's 
knee, with her head and legs hanging down. 

On admission, the girl was in good condition and had a florid com- 
plexion. Her weight was twenty-two pounds ten ounces. Her liver and 
spleen were of normal size, and the heart and lungs were healthy. The 
abdomen was unusually compressible. The aorta and iliac arteries could 
be felt pulsating on deep pressure, and both kidneys could be felt. They 
were not tender when touched, and seemed in every way normal. She 
passed water more frequently than was natural, but there was no pain in 
micturition. Her skin was not harsh, acted fairly well, and there was no 
sign of oedema. The urine was dark with blood, of specific gravity 1.024, 
threw down a copious precipitate on boiling, and showed an abundance of 
blood-corpuscles under the microscope. After a few days stellate crystals 
of uric acid were also discovered in the sediment. 

The child was kept in bed, and was given a mixture containing carbo- 
nate of potash. The amount of blood in the water gradually decreased, and 
in five days had quite disappeared. The urine then became perfectly 
normal, and ceased to contain albumen or blood-corpuscles. There were 



766 DISEASE IN CHILDKEN. 

never any signs of casts, of purulent matter, or of mucus. No pain was 
noticed during her residence in the hospital, and she was soon discharged. 
About a month afterwards she was readmitted with the same symptoms, 
but they quickly disappeared as before with rest and alkalies. Her tem- 
perature was always normal. 

This case is a good illustration of the symptoms produced in children 
by renal concretions in the kidne}'. It would be difficult to attribute the 
hematuria to any other cause. The significant fact that the bleeding oc- 
curred for the most part after exercise, and that until the amount of blood 
became excessive, the water was clear in the morning when the child first 
rose from her bed, were strong arguments in favour of urinary concre- 
tions. The patient, besides, was in good condition, and of a healthy ap- 
pearance, and although her kidneys could be felt on palpation, no increase 
in their size could be detected. Lastly, crystals of uric acid were found in 
the sediment. 

Examination of the urine in these cases often gives a negative result. 
Calculus may exist in the kidney without giving rise to symptoms of any 
kind. Between the attacks of hsematuria the water may contain neither 
blood nor albumen, and unless sand or crystals of uric acid be actually 
passing, it may redden litmus paper but faintly. 

Sometimes the irritation produced by the presence of the calculus in 
the pelvis of the kidney may set up pyelitis. The stone then usually be- 
comes enlarged by deposition of phosphatic salts upon its surface. 

A child was admitted into the East London Children's Hospital, suffer- 
ing from tubercular meningitis. After death, which took place in two days' 
time, besides the morbid appearances usual in such cases, the left kidney 
was found to be extensively diseased. The organ was much enlarged and 
contained about two ounces of creamy pus. In the interior it was hollowed 
into cavities, and its proper substance was almost replaced by caseous 
matter. A calculus of the size of a cherry-stone was impacted in the upper 
part of the ureter. Above this, the ureter and pelvis of the kidney were 
much dilated. In this case, no doubt, the stone had first, by the irritation 
it produced, set up pyelitis, and had then become impacted in the ureter, 
preventing the escape of the purulent matter. 

When the concretion passes from the kidney into the ureter, and down- 
wards into the bladder, there is always pain ; but the child suffers far less 
than an adult would do under similar circumstances. Sometimes an attack 
of abdominal pain in a child, attributed, as all such pain is apt to be, to 
abdominal derangement and colic, is followed by symptoms of stone in the 
bladder. It is therefore desirable in all cases where pain, more than or- 
dinarily severe, appears to be suffered, to examine the state of the child's 
water, and inquire of the nurse whether sand or gravel has been seen at 
the bottom of the chamber-pan. 

If the stone becomes impacted in the ureter, serious consequences may 
ensue. The irritation of the foreign body in this situation may set up in- 
flammation, and give rise to thickening and contraction immediately above 
the seat of the impediment. Higher up the ureter becomes greatly dis- 
tended, and the pelvis of the kidney may suffer dilatation. In some cases 
the pressure of the secreted fluid, accumulating in the channels above the 
obstruction, may flatten out the kidney into a thin-walled cyst. This is 
one form of hydronephrosis. 

When the stone has entered the bladder, urgent symptoms begin to be 
noticed. This affliction is more common in boys than in girls ; probably 
for purely mechanical reasons. The urethra in girls is short, straight, 



CALCULUS OF THE KIDNEY — SYMPTOMS — DIAGNOSIS. 767 

and, when the child stands upright, almost vertical. In boys it is long 
and sinuous with a double bend. In the bladder the stone produces great 
irritation. Priapism is common ; and there is usually pain, which is in- 
creased by exercise. During micturition the boy cries with pain, which he 
refers to the end of the genital organ, and endeavours to relieve by squeez- 
ing and rubbing the part with his fingers. The flow of urine often stops 
suddenly, from the stone being carried by the flow of water into the neck 
of the bladder, and there forming an impediment to the escape of the 
urine. Consequently the water is voided with effort, and the straining 
may give rise to prolapse of the rectum. Actual retention may occur, the 
stone being tightly grasped by the sphincter vesicae, and impacted at the 
beginning of the prostatic urethra. A little pure bright blood may be 
passed at the end of micturition, and the urine often gives evidence of se- 
vere catarrh of the bladder. Any of these symptoms occurring in a boy 
should make us inquire very carefully into the cause of his complaints. 
It must not, however, be forgotten that very similar symptoms may arise 
from different reasons. Dr. West has pointed out that in cases where the 
prepuce is abnormally long, with a narrow opening, its edges may become 
very sore on account of the difficulty and delay with which urine is forced 
through the orifice ; and this may give rise to much pain in micturition. 

Diagnosis. — On account of the frequency with which uric acid concre- 
tions are found in the urine of children, it is evident that the delicate 
membrane lining the tubules of the kidney is liable to be exposed to injury 
from the sharp edges of the crystalline masses. Consequently, hsernor- 
rhage in such cases is no matter for surprise. The wonder, indeed, is that 
it is not a more common symptom of uric acid sand in young persons. 
That it is not so is probably due to the fact that the uric acid is commonly 
deposited from the urine in the bladder itself, and not at a higher point in 
the urinary apparatus. Sir Thomas Watson has recorded his opinion that 
many of the obscure cases of hsematuria in the adult may be referred to 
renal calculi. In the case of children it may be laid down as a rule that 
renal haemorrhage occurring in a child otherwise healthy, and accompanied 
by no symptoms, nor by haemorrhage from other parts of the body, is, in the 
majority of cases, to be attributed to the irritation of crystalline masses in 
the tubules, calices, or pelvis of the kidney. 

Not long ago I saw a little boy, aged ten months, who for six weeks 
had been passing water mixed largely with blood. Sometimes for a few 
days together the water would be clear, but the haematuria speedily re- 
turned. The specimen brought with the child was bright crimson in col- 
our, and consisted of blood and urine intimately blended together. It had 
a slightly acid reaction. Many blood-corpuscles were seen under the mi- 
croscope, bu r no crystals of uric acid could be detected, although the med- 
ical attendant had occasionally found them in the sediment. The child 
had been brought up by hand and fed upon cow's milk and water. He 
had no teeth, could not stand, and showed signs of being under-nourished. 
The bowels were confined habitually ; otherwise he seemed to suffer no dis- 
comfort, and was said never to be peevish or fretful. 

As the infant was evidently insufficiently fed, I rearranged his diet, order- 
ing one meal in the morning of oatmeal (one teaspoon ful) with cow's milk, 
two meals of Nestle's milk food, and two or three meals of Mellin's food 
with cow's milk diluted with a third part of barley-water. I also prescribed 
a mixture containing the infusions of senna and gentian, so as to act gently 
upon the child's bowels. 

Some months afterwards I heard that the bleeding had continued for a 



768 DISEASE IN CHILDREN. 

few weeks longer ; that the child had then seemed in great pain for a day 
and a night ; but that after this the water had become clear, and had ever 
since been perfectly free from blood. The nutrition had begun to improve 
immediately upon the change of diet. 

There can be little doubt that the hematuria in this case was the con- 
sequence of irritation of the kidney by a small angular concretion ; and 
the pain spoken of was, in all probability, an attack of renal colic, caused 
by the passage, or attempted passage, of the little calculus down the ure- 
ter. In cases such as this, the concretions must be looked for carefully in 
the urine passed at the end of a fit of colic. They are often no larger 
than a mustard-seed, or even a small pin's head. 

Prognosis. — The occasional appearance of free uric acid in the urine of 
infants and children is of no consequence whatever. The frequent passage 
of sandy particles is of greater moment, for in these cases we are justified 
in fearing the formation of a stone in the bladder. A mere passing hema- 
turia should not have too much importance attached to it ; for it is prob- 
able that a certain oozing of blood may occur in the kidney, as a con- 
sequence of irritation from small crystalline fragments, which may be 
afterwards washed away. Repeated haemorrhage from this source is, 
however, to be regarded with anxiety ; and if there are signs of pain in 
the renal region preceding or accompanying the flow of blood, we have 
reason to fear the presence of a calculus, and further ill-consequences are 
to be anticipated. 

Treatment. — The frequent appearance of uric acid crystals, or of sandy 
deposits, or even the habitual presence of urates in a child's water, should 
make us inquire very carefully as to the food he takes, and the general 
conditions under which he is living. Such a child should live plainly. 
He should take meat once a day with vegetables, and a light custard or 
batter pudding. For his other meals he should have milk and bread-and- 
butter, with occasionally the yolk of an egg or a little bacon for his break- 
fast. Care should be taken that he does not overload his stomach, and 
the quantity of farinaceous food he eats should be duly proportioned to 
his power of digesting it. Sweet things should be given to the child with 
caution ; and all cakes and biscuits between meals should be strictly for- 
bidden. He should take exercise freely in the open air. His skin should 
be kept in good order by complete washing every day, and in the colder 
months he should be dressed from head to foot in some warm woollen 
material. Great attention should be paid to the ventilation of his bed- 
room, and in the winter he should be dressed and undressed in a well- 
warmed room. In the case of an infant, vigilance should be exercised 
that the child does not take too large a quantity of food at one time, and 
that he is not burdened by too much farinaceous matter to his meals. 
Cleanliness and plenty of fresh air must be always insisted upon. 

In addition to the above measures, care should be taken that the patient 
drinks sufficient fluid to freely dilute the renal secretion. Remembering 
that a concentrated state of the urine is alone sufficient to give rise to 
sandy deposits in the urine, the child should be made to drink half a tum- 
bler of water, fasting, one hour before food, twice a day. This simple 
precaution, in many cases, will at once put an end to any appearance of 
sand. An infant may be given thin barley-water from his bottle with the 
same object. 

For medicine, alkalies, such as the citrate of potash, should be given, 
and the treatment must be continued for several weeks. If haemorrhage 
occur, perfect rest in bed must be enforced. These cases seldom require 



CALCULUS OF THE KIDNEY — TREATMENT. 769 

styptics, but if thought advisable, a few grains of gallic acid may be given 
with dilute sulphuric acid twice a day. 

If, from attacks of pain or frequent haemorrhages, it becomes evident 
that the child has a calculus of the kidney, citrate of potash should be 
given in sufficient doses to keep the urine slightly alkaline ; and this 
treatment should be persevered with in the hope of dissolving the concre- 
tion, or at any rate of reducing its size sufficiently to enable ifc to escape 
by the ureter. If great irritation and pain are produced by the continued 
presence of the calculus, and the health and strength of the child seem to 
be seriously affected, the question of nephrotomy should be considered. 

In an attack of nephritic colic, the child should be kept under the in- 
fluence of morphia, and hot fomentations must be applied to the abdomen. 

49 



CHAPTER IT. 

TUMOURS OF THE KIDNEY. 

Tumours of the kidney are occasionally seen in children, and generally 
occur in the form either of a sarcomatous growth or of a hydronephrosis. 

Sarcoma of the kidney constitutes the ordinary form of renal cancer 
met with in the child. It occurs usually at an early age (the cases which 
have come under my notice have been all under three years old), and is 
usually confined to one side of the body. In the kidney, as in other or- 
gans, the growth often reaches a very large size. 

Morbid Anatomy. — The sarcoma is usually of the round-celled variety ; 
but the tumour often contains, in addition to sarcoma tissue, striated mus- 
cular fibre scattered or arranged in bundles. Under the microscope these 
tumours are found to have a fibrillated structure, some fibres being slightly 
spindle-shaped, with an indication of a nucleus ; others, more elongated, 
with signs of transverse striation ; others, again, well-developed, with dis- 
tinct striation. But even in the best developed fibres no sign of a sarco- 
lemma can be seen. In some cases the new muscular and sarcomatous 
tissue is dispersed through the kidney substance, and the tumour is then 
really a tumour of the kidney. In other cases the new tissue seems to be 
separated from the kidney substance proper, although lying within the 
capsule ; or it divides the organ into two parts without, as in the other 
case, infiltrating its substance. It has been suggested that these growths 
may be derived from the remains of the Wolffian body. 

Symptoms. — No pain seems to attend the development of these tu- 
mours, and at first there is little interference with the general health. 
Consequently, the earliest sign to attract the attention of the attendants is 
the unusual size of the child's belly ; and the mother often complains that 
the belly feels harder on one side than it does on the other. 

On examination, in such cases, we find a globular swelling occupying 
one side of the abdomen. The swelling is usually little movable, and 
does not descend, or moves very slightly, in inspiration. Its borders are 
rounded, and there is no edge felt, as is the case with the spleen. Its 
substance is soft and elastic, so as to convey an imperfect sense of fluctua- 
tion. Below, the fingers can be pressed between the lower border and 
the brim of the pelvis ; above, the tumour passes beneath the liver, or on 
the left side is continuous with the splenic dulness beneath the false ribs ; 
externally, the swelling reaches backwards into the loin, and there is 
seldom any intestinal resonance to be detected between it and the spine. 

As the tumour grows the only inconvenience felt is the weight of the 
mass in the abdomen. The appetite is good, often exceptionally keen, 
and nutrition is fairly performed. The urine is usually normal, although 
in some cases it may contain albumen and blood ; and towards the end it 
may be scanty, with infrequent micturition. 

After a time, as the size of the growth increases, secondary derange- 



TUMOURS OF THE KT.DNEY — SYMPTOMS. 771 

inents from pressure begin to be noticed. The earliest sign that the growth 
is interfering with neighbouring parts is usually an enlargement of the su- 
perficial veins of the abdominal wall from pressure upon the vena cava. This 
is often followed by oedema of the lower limbs and scrotum. Sometimes 
the liver enlarges from passive congestion ; and dyspnoea may be induced 
from pressure upwards of the diaphragm by the renal mass. When these 
signs are noticed nutrition becomes affected, and the end is not far off. 
The child gets thinner, and soon wastes rapidly. His appearance becomes 
cachectic ; aphthae develope in the mouth, and he sinks and dies. Before 
death the emaciation may be extreme. 

These symptoms are well illustrated by the case of a patient in the 
East London Children's Hospital, under the care of my colleague, Dr. 
Donkin, through whose kindness I had several opportunities of examin- 
ing it. 

A little girl, aged two and a half years, was brought to the hospital on 
account of a swelling of the belly. The mother stated that she had no- 
ticed three months before that the belly was large and hard on one side, 
and that a doctor had said there was a tumour of the abdomen. For a 
month the child had been languid and fretful, picking her nose, and 
moaning in her sleep. Now and then she had complained of abdominal 
pains, and once or twice she had vomited. The bowels were disposed to be 
costive, and the water was occasionally milky (from lithates). 

The child was full-grown for her age and well-nourished. She did not 
look ilk The abdomen was large and full, especially on the right side, 
and the superficial veins were distended. On palpation of the belly a 
large, oval, smooth mass was felt on the right side, reaching from the liver 
to the level of the brim of the pelvis. The fingers could be passed un- 
der the lower border of the tumour, and above could be pushed a little 
way between the upper border and the liver, the edge of which could be 
distinctly felt overlapping the upper part of the mass. Anteriorly, the 
swelling reached beyond the middle line of the belly, and its limits could 
be distinctly felt rounded and resisting. Posteriorly, the tumour passed 
backwards into the renal region, and its boundaries in this direction could 
not be ascertained, although when the child lay on her left side the reso- 
nance of the intestine could be made out posteriorly. In front the colon 
could be detected lying on the surface of the swelling. 

The whole tumour was very slightly movable ; its surface was smooth ; 
its substance elastic, and it felt like a tense bag of fluid. There was no 
ascites ; no enlarged glands could be felt in the groins or elsewhere ; the 
edge of the liver reached two fingers' breadth below the ribs ; there was 
no enlargement of the spleen. In order positively to exclude fluid, an ex- 
ploratory puncture was made into the tumour, but nothing but a little blood 
was withdrawn. The temperature remained normal after the puncture. 

For a fortnight after the child's admission there was little change in 
her condition. Then, however, her temperature rose ; she vomited, and 
began- to look ill and careworn, and a pneumonia developed in the base 
of the right lung. The urine became intensely acid ; it was loaded with 
urates, and deposited large amounts of uric acid on standing ; there was 
also a trace of albumen. The liver enlarged ; the veins of the abdominal 
wall became engorged with blood ; oedema occurred in the lower limbs ; 
the face got dusky ; general convulsions came on, with epistaxis and bleed- 
ing from the ears, and the child died in a few minutes. 

On examination of the body a round-celled sarcomatous tumour, the 
size of a foetal head, was seen occupying the lower two-thirds of the right 



772 DISEASE IN CHILDREN. 

kidney, infiltrating its tissue. It was covered by the renal capsule. Its 
substance was of soft pulpy consistence in the centre, harder and firmer 
towards the circumference. There was one large haemorrhage into its lower 
part. The tumour pressed upon the inferior vena cava, which was dis- 
tended by a large decolourised thrombus, perforated in the middle by a 
channel of the diameter of a goose-quill. The thrombus reached from the 
level of the tumour upwards to the right ventricle of the heart. The liver 
and spleen were both much congested. 

This case may be considered a typical example of a renal tumour. The 
only doubt possible was as to the nature of the swelling, and this the 
exploratory puncture removed at once. Fluid being thus excluded, the 
rarity of any other form of solid growth made the diagnosis of sarcoma 
comparatively an easy one. 

Sarcomatous tumours of the kidney generally grow rapidly, and the 
course of the disease is seldom protracted. Death often occurs within a 
year of the swelling being first discovered, and in the longest case life is 
rarely prolonged beyond eighteen months. 

Hydronephrosis is almost invariably in children a congenital affection. 
It is often associated with some form of arrest of development, such as club- 
foot, harelip, imperforate anus, or absence of the prostate gland. Both kid- 
neys are more often affected than one alone, and the most common cause is 
impervious ureters or an imperforate urethra. According to Dr. Englisch, 
the obstruction may take its rise in the valvular folds, situated at the upper 
part of the ureter, or at its lower part ; and in five cases he referred the 
cause of the obstruction to a curving of the mucous membrane at the orifice 
of the urethra into a diverticulum. 

In rare cases the disease is acquired during childhood from impaction 
of a calculus in the ureter. The other causes of acquired hydronephrosis, 
viz., retroflexion and prolapse of the womb, etc., do not come into play 
until a more advanced period of life. 

Whatever be the cause of the retention, the essence of the disease con- 
sists in accumulation of urine in the pelvis of the kidney. The pressure 
of this fluid produces very serious consequences. Every degree of dilata- 
tion of the parts is seen according as to whether the fluid can partially es- 
cape or is wholly retained. In every case the renal pelvis is greatly 
dilated, but there are many degrees of alteration of the kidney substance, 
from mere flattening and toughening of the papillae to actual conversion 
of the organ into a membranous sac filled with fluid. If the obstruction 
is low down in the ureter, this tube is also dilated and its wall thickened. 
The fluid has a low specific gravity, and contains the elements of urine al- 
though in feeble proportion ; i.e., urea, uric acid, urates, and often crystals 
of oxalate of lime. Its reaction is faintly alkaline. Its colour is clear amber 
or turbid, and may be yellow from pus or reddish from blood. Some- 
times it contains epithelium, and in rare cases the consistence is increased 
to a thick fatty fluid. 

Symptoms. — Although almost invariably congenital, the hydronephrosis 
is often not noticed until several months or even years have elapsed from 
birth. The mother then observes that the abdomen is enlarged, and that 
the chief swelling is limited to one side of the belly. Her attention being 
thus directed, to the child's abdomen she finds that this progressively in- 
creases in size, and a medical practitioner is consulted. 

The tumour is a painless one and forms a soft elastic swelling in the 
situation of the kidney. The cyst sometimes reaches a large size, and 
may cause great inconvenience by its weight, or interfere with respiration 



TUMOURS OF THE KIDNEY — SYMPTOMS — DIAGNOSIS. 773 

by pressing upwards against the diaphragm. The lumbar region on the 
affected side is then seen to be prominent as the child lies on his face, and 
fluctuation is transmitted freely from the front to the back. In a case re- 
corded by Dr. Hillier — a child three years and a half old — the swelling 
filled the whole abdomen, and five pints of clear non-albuminous fluid 
were withdrawn by tapping. Sometimes an escape of some of the retained 
fluid occurs from time to time, and the size of the tumour may thus undergo 
marked variations. If the accumulation be due to an impacted calculus, 
attacks of nephritic colic may occur, with bloody urine, if both kidneys 
are affected, and the escape of fluid is entirely prevented, the child may 
die with symptoms of uraemia. Such a condition is of course incompat- 
ible with life, and if it be a congenital one, the child is generally stillborn. 

Diagnosis of Renal Tumours. — We have first to satisfy ourselves that 
the tumour is due to enlargement of the kidney, and then to ascertain the 
nature of the swelling. In order to arrive at an accurate diagnosis, a 
careful examination of the abdomen is of course indispensable ; so that if 
the child is fretful and unmanageable, crying and contracting his abdom- 
inal walls, he should be put under the influence of an anaesthetic. 

A rounded mass in which no edge can be detected, situated in the 
region of the kidney, and little affected by respiration ; one which does 
not dip into the pelvis, but passes upwards to the liver or spleen and 
backwards into the lumbar region — such a tumour is in all probability an 
enlarged kidney. Renal tumours may be confounded with tumours of any 
other abdominal organ, or indeed with a swelling anywhere within the 
abdominal cavity. 

On the right side the renal enlargement must be distinguished from a 
tumour of the liver. The latter rises and falls with respiration, and will be 
noticed to lie close up under the ribs so that the fingers cannot be passed 
between its upper border and the diaphragm. • Moreover, a hepatic tumour 
is rarely covered by a coil of intestine ; and on careful manipulation the 
edge can usually be detected. This, of course, at once excludes the kidney, 
for a kidney, whether enlarged or not, is rounded in all directions. 

On the left side a splenic tumour must be excluded. Enlargements of 
the spleen are very common in children, but they can never be mistaken 
for a kidney by a careful observer. An enlarged spleen lies very super- 
ficially ; its position is markedly influenced by respiration ; it is freely 
movable ; it has a distinct edge towards the middle line, in which the notch 
can usually be felt, and its upper border passes upwards beneath the ribs. 

On either side the renal tumour may be mistaken for a mass of enlarged 
glands, a psoas abscess, faecal accumulations, and, in girls, ovarian enlarge- 
ments. 

Enlarged glands lie very deeply against the spine, and have to be felt 
for with care. They are only slightly movable. Still, palpation alone may 
be insufficient to distinguish a swelling of this kind from an enlarged 
kidney. By attention, however, to the general symptoms, we may usually 
arrive at a conclusion. A kidney only slightly enlarged from sarcoma pro- 
duces no impairment of the general health ; while caseous glands, suffi- 
ciently large to be detectable by the touch, are associated with a history 
of ill-health or of more or less interference with nutrition. The patient 
has usually suffered from attacks of diarrhoea, and may perhaps have signs 
of chronic ulceration of the bowels. In such a case he would look ill even 
although the bowels were not actually loose. 

A psoas abscess, like a renal tumour, occupies the region of the loins 
and extends forwards into the belly. It is, however, placed more deeply 



774 DISEASE IN CHILDREN. 

than a tumour of the kidney, and cannot be so easily felt. Little informa- 
tion is to be derived from the presence of fluctuation in the swelling ; for 
this is difficult to ascertain in a psoas abscess, and a sarcomatous kidney 
conveys a sense of pseudo-fluctuation which is often very deceptive. A 
far more important distinction is that furnished by the actual position of 
the mass, for a renal tumour reaches far higher in the abdomen than an 
abscess. Moreover, the latter is distinctly tender on pressure, while the 
kidney tumour is quite painless. Lastly, in psoas abscess, although there 
may be no curvature of the spine, careful examination will often discover 
the existence of disease of the vertebrae (see page 185). 

Other abscesses in the neighbourhood of the kidney can usually be de- 
tected by their causing enlargement behind in the renal region. Accord- 
ing to Sir William Jenner, this is rarely the case with a simple swelling of 
the kidney. 

Fsecal accumulation may be, perhaps, mistaken for a renal -tumour; 
but a mass sufficiently large to give rise to hesitation must be very rare in 
the child. Fsecal lumps lie veiy superficially, and can be indented with 
the finger. Besides, they can be cleared away by a copious injection. 

Ovarian tumours are sometimes found in little girls. These dip down 
into the pelvis, and the fingers cannot be passed beneath their lower bor- 
der. Moreover, they are rarely covered by coils of intestine. These are 
all pressed away towards the lateral regions of the groin. 

Having ascertained the existence of a renal tumour, it is sometimes 
very difficult to decide upon its nature. If the tumour be double, or be 
accompanied by signs of severe nephritic colic, it is probably due to a 
hydronephrosis. So, also, if the swelling is noticed to be diminished in 
size after a copious flow of urine, it may be attributed to the same condi- 
tion. Usually the doubt can be only removed by an exploratory puncture 
of the swelling. If fluid be withdrawn containing urea, there can be no 
further hesitation as to the nature of the tumour. 

The distinction between hydronephrosis and ascites is described in the 
chapter treating of the latter disease (see page 703). 

Treatment. — In cases of sarcoma of the kidney we can do nothing but 
attend to the general nutrition of the patient. In the case of hydrone- 
phrosis : — If occasional reductions in the size of the tumour have been 
noticed to follow a copious discharge of urine, friction and shampooing of 
the abdomen, such as proved successful in a case reported by Dr. W. 
Roberts, may be made use of. In other cases occasional tapping may 
greatly relieve the patient. Dr. Day reports a case in which nephrectomy 
was successfully performed by Mr. Knowsley Thornton, and the child re- 
covered. A cure may, how T ever, be effected by a less serious operation. 
It appears from a case recorded by Dr. Tuckwell, and Mr. H. P. Symonds, 
of Oxford, that persistent drainage of the sac may sometimes lead to its 
shrinking and contraction. In the case referred to — a boy eleven years of 
age — an incision was made into the sac in the lumbar region, and a large 
drainage-tube was introduced through the opening. Antiseptic dressings 
were employed, and at the end of thirteen weeks from the operation the 
tube was finally removed. The child recovered perfectly, and six months 
afterwards no sign of the tumour could be discovered on examination of 
the belly. Operative interference in these cases should not be undertaken 
unless a healthy state of the urine indicates that the opposite kidney is 
free from disease. 



CHAPTER V. 

VULVITIS. 

Vulvitis, or vulvovaginitis (for the catarrhal inflammation of the mucous 
membrane often penetrates for some distance into the vaginal canal), is 
very common in little girls. The complaint may be seen at a very early 
age, even during the first few months of life ; but is more common in 
children of five years of age and upwards. M. Parrot has described a 
variety of the derangement which he calls " aphthous vulvitis," and states 
that it is met with most frequently in children between the second and 
fourth year. 

Causation. — Catarrhal vulvitis is especially common in children of 
scrofulous constitution, and appears to be excited by want of cleanliness 
and insanitary conditions generally ; also by local irritation in the neigh- 
bourhood, as by ascarides in the rectum. In very rare cases it may be the 
consequence of sexual violence. Certain forms of the complaint appear to 
be contagious and capable of being communicated from one child to an- 
other by sponges or towels ; and Dr. Atkinson, of Baltimore, has stated 
his belief that the discharges from a purulent ophthalmia may be conveyed 
to the vulva, and set up a similar inflammation in that situation. 

Vulvitis is sometimes a secondary disease. Thus, it may come on after 
some of the acute specific diseases. Parrot has seen aphthous vulvitis 
succeed most commonly to measles, next to whooping-cough. He has also 
met with it after varicella, erysipelas, pneumonia, and diphtheria. In 
only a few cases was it apparently a primary derangement. 

Symptoms. — In catarrhal vulvitis a purulent discharge may be noticed 
to issue from the vulva. At first it is scanty, and is seen on the child's 
body linen. On inspection of the parts the mucous membrane is found to 
be red, and the larger labia to be a little swollen. The discharge is yel- 
lowish or greenish in colour. It is usually fetid, and in many cases is 
very profuse. In hospital out-patients, who are often neglected in the 
matter of cleanliness, the opening of the vagina is often found bathed with 
a thickish, yellow, offensive matter. If the catarrh is not quickly cured, it 
may lead to considerable swelling of the labia, and the mucous membrane 
may become excoriated. In these cases there may be some pain in walk- 
ing ; and if the catarrh extends to the orifice of the urethra, there may be 
smarting in micturition. There is not usually any enlargement of the in- 
guinal glands ; but in bad cases, occurring in unhealthy, neglected chil- 
dren, irritable sores may form on the inner surface of the labia, and the 
glands may then become slightly swollen, and a little tender. I have 
never ssen suppuration of these glands. If left untreated, spontaneous 
recovery may take place, or the discharge may become chronic, and per- 
sist for months or even years. The swelling in these cases subsides, but 
thin purulent matter, small in quantity, continues to be secreted. I have 



776 DISEASE IT* CHILDREN. 

thought, in some of these chronic cases, that irritation has been kept up 
by a habit of masturbation. 

Aphthous vulvitis, according to Parrot, attacks the labia majora, and 
sometimes the smaller lips and the clitoris. From these parts the aphthous 
inflammation may spread to the genito-crural folds, the groins, the peri- 
nseum, and the borders of the anus. It begins by an eruption of small, 
rounded, or semi-spheroidal elevations of the epidermis, of a grayish white 
colour, and often depressed in the centre. The little patches closely re- 
semble the aphthous spots on the buccal mucous membrane, and are sur- 
rounded by a red, slightly-swollen ring. In number they are five or six 
to fifteen, and may be placed singly or in groups ; sometimes they are 
confluent. After a period varying from thirty-six hours to three days, the 
patches give place to ulcers which have a gray or yellowish base, and a red 
border. They cause considerable irritation, which it is difficult to prevent 
the patient from relieving by the use of the fingers. At the height of the 
disease the edges of the sores are raised, and the parts around, especially 
the minor labia and the clitoris, are swollen and bright red. Under suita- 
ble treatment the swelling soon subsides, and the ulcers heal ; but in un- 
healthy subjects the lesion may take on a gangrenous process. When this 
occurs the constitutional symptoms are severe, and the gangrene may 
spread extensively, and present all the features described elsewhere (see 
Gangrene of the Vulva, page 170). 

Diagnosis. — Vulvitis is a very common derangement amongst the chil- 
dren of the poor, but may be found in any condition of life. Knowing 
its frequency, we must be on our guard against accepting any suggestion 
(such as some mothers are very ready to make) that their child has been 
tampered with by a person of the opposite sex. If this have really taken 
place, we should expect to find ecchymosis and recent abrasions of the 
external genitals. The hymen is rarely ruptured, on account of the small- 
ness of the passage. 

The aphthous spots are distinguished from mucous patches by the ab- 
sence of all signs of constitutional symptoms in the child. The ulcers are 
distinguished from venereal sores by the absence of any hardening at the 
base. Moreover, the latter are never grouped or confluent, as is almost 
invariably the case with the aphthous ulcers. 

Treatment. — The utmost cleanliness must be observed. The parts 
should be bathed frequently or syringed with warm water, and afterwards 
a little pledget of cotton-wool, soaked in a mild lead lotion, should be 
passed between the labia. If the catarrhal inflammation seem to have ex- 
tended into the vagina, the lotion may be injected with a syringe. If 
there be great irritation of the parts, a weak solution of perchloride of 
mercury (one grain to eight ounces of water) may be used instead of the 
lead. If the case be obstinate, the parts should be well dabbed with 
a weak solution of nitrate of silver (gr. vj.-x. to the ounce of distilled 
water). 

Dr. G-aillard Thomas recommends for all obstinate cases the careful 
syringing of the vagina with warm water, and the use afterwards of a lotion 
composed of one ounce of black wash to the pint of water. The lotion 
must be injected with a syringe twice a day, and on each occasion the pas- 
sage must be previously cleansed by careful injection of warm water. Dr. 
Thomas attributes the chronic course of many of these cases to the imperfect 
application of remedies. He urges the importance of instructing the mother 
in the use of the syringe, directing her to introduce the nozzle of the instru- 
ment well into the vagina, so that the upper part of the passage is reached 



VULVITIS — TREATMENT. 777 

by the fluid. In all instances where the child is anaemic or of scrofulous 
aspect, iron wine and cod-liver oil should be given internally. Care must 
also be taken that the bowels are regularly relieved, and that objectionable 
habits are no longer continued. 

In the aphthous form of vulvitis, Parrot recommends the use of the 
powder of iodoform once a day thoroughly after careful washing. He 
then applies a covering of lint. Parrot states that this application quickly 
cures the sores, and prevents the occurrence of gangrene. 



Part 12. 
DISEASES OF THE SKIN, 



CHAPTEE I. 

DISEASES OF THE SKIN. 



In childhood the skin shares the general susceptibility of the whole sys- 
tem, and is very liable to disease. At this period of life the surface of 
the body is delicate and readily irritated by the presence of accumulated 
dirt and dried secretion. Amongst the poor, neglect and want of cleanli- 
ness are common causes of cutaneous affections in the young. Moreover, 
in the young subject, gastro-intestinal derangements are especially liable 
to be accompanied by the various forms of erythema ; and childhood ap- 
pears in itself to increase the susceptibility to the parasitic diseases of the 
skin. In a work treating of disease in early life, a consideration of the 
various eruptions to which childhood is liable must not be entirely neg- 
lected ; but attention will be confined to the more common forms of skin 
disease met with at this period of life, and the subject must necessarily be 
discussed somewhat cursorily, and chiefly with a view to diagnosis and 
treatment. 

The papular eruptions do not require very extended notice. Lichen is 
very rare in the young subject. The form called lichen urticatus is the 
most common ; but this eruption appears to be more a modification of net- 
tle rash than a true lichen, and will be afterwards referred to under the 
head of urticaria. 

Prurigo is occasionally met with in dirty, neglected children in the 
form of slightly projecting papules, which give rise to considerable irrita- 
tion ; but in early life the rash seems to induce a less intense form of itch- 
ing than that which is a cause of so much suffering to older persons. Mr. 
Hutchinson has described a prurigo of infants which appears often to be 
a sequel to or modification of chicken-pox ; and he is disposed to believe 
that an abortive varicella is often the original cause of the outbreak. The 
papules are hard and rough, and may be mixed up with wheals of urticaria. 
In some cases they are large, and resemble half-developed wheals of nettle^ 
rash, "with perhaps even some tendency to vesication." The itching aris- 
ing from the eruption is often greatly relieved by the use of warm baths, 
medicated with the liq. carbon is detergens, in the proportion of two tea- 
spoonfuls to the gallon of water. This bath should be used twice a day. 
The skin may be afterwards anointed with a salve composed of one ounce 



DISEASES OF THE SKLN"— STKOPHTILUS — PEMPHIGUS. 779 

of storax, two drachms of white wax, and half an ounce of olive-oil. If the 
child is feeble or delicate, cod-liver oil and iron wine should be prescribed, 
and the diet should be regulated on the principles elsewhere recommended 
(see Infantile Atrophy). 

Strophulus is a common eruption in infants, and usually arises as a con- 
sequence of laboured digestion. It is met with in two principal forms — a 
red and a white variety. Red strophulus consists of small red papules of 
the size of a large pin's head. These papules often occur in groups, and 
occupy the face, the trunk, and sometimes the limbs. They cause some 
itching. In white strophulus the colour of the papules is pearly white. 
Each papule lasts a few days, and the rash usually comes out in successive 
crops. It is not accompanied by any general symptoms, and the only 
treatment required is attention to the digestive organs, and some necessary 
modification in the diet. 

Of the vesicular and bullous group, herpes and pemphigus are both far 
from rare. Herpes of the lip is as common a symptom of croupous pneu- 
monia in the child as it is in the adult. Herpes of the pharynx is de- 
scribed elsewhere (see page 580). Herpes zona is comparatively rare in 
the child, but is sometimes seen, and then differs little from the same 
eruption in the adult except that it is much less frequently followed by 
intercostal neuralgia. It requires no treatment. 

Pemphigus is occasionally met with in the child. In new-bom infants 
a syphilitic form of the disease is not uncommon, and usually indicates 
profound contamination of the system. Syphilitic pemphigus is referred 
to elsewhere. 

Pemphigus attacks ill-nourished children, and may be found to occur 
during convalescence from acute febrile diseases such as scarlatina. It is 
also apt to be met with as a frequently recurring complaint in children of 
fairly robust appearance, and in such cases it is difficult to know what is 
the cause of the repeated returns of the bullous eruption. In the more 
common variety of the disease the eruption begins in the form of small 
red spots. On these spots the cuticle rises rapidly into a bleb, which in- 
creases in size until it is as large as a marble or a walnut. The bladders 
thus formed are tense, and filled with fluid, and their base is surrounded 
with a red zone of inflammation. The fluid is at first clear, but soon be- 
comes opaque. The blebs may last unbroken for some days, but usually 
they burst very early, and give place to thin yellowish brown scabs on a 
purplish ground. The eruption comes out in successive crops. Many 
blebs do not appear at one time, but the repeated succession of crops 
covers the body with bladders, crusts, and stains from the various stages 
of the affection being simultaneously present on the skin. All parts of 
the body may be affected, even the lips and the ears, but the palms and 
soles usually escape. The appearance of the eruption is accompanied by 
some constitutional disturbance, which is often found to vary in severity 
according to the extent of surface involved in the disease. There may be 
some fever. In a boy aged eight years, who was admitted into the East 
London Children's Hospital with extensive pemphigus, the temperature 
during the first three days was over 101° both morning and evening, and 
for a fortnight afterwards it rose sometimes in the evening to 99.8° or 100°. 
Thirst, restlessness, and loss of appetite are also noticed, and there is some- 
times diarrhoea. The eruption at first may be accompanied by some 
itching, but after the bursting of the blebs the resulting sores cause pain 
and smarting. 

An occasional form of the disease is that called pemphigus solitarius, 



780 DISEASE IN CHILDREN. 

where a single bleb rises on the hand or foot, often on one finger, and 
quickly attains a great size. Sometimes the bleb involves the whole of 
the hand. Mr. Naylor described a variety of pemphigus which he called 
" pompholyx diutinus in children." This form begins like ordinary pem- 
phigus as a small red spot, which becomes a bleb and rapidly enlarges. 
After the bladder has ruptured the sore still continues to spread, and be- 
comes covered with a thin wrinkled crust with a narrow raised rim, the 
remains of the bleb. The disease appears to be a purely local one, and the 
general health is quite unaffected. Dr. E. Liveing has doubts if this af- 
fection be a true pemphigus. 

The sore of pemphigus, like other sores, ma}'' assume a gangrenous 
form in unhealthy, cachectic children. The resulting condition is very 
much that already described as a consequence of gangrenous varicella (see 
page 49). 

The duration of the disease is apt to be prolonged, and sometimes the 
eruption returns very rapidly after apparent cure. The nature of the 
affection can hardly be mistaken, for the large blebs or blisters surrounded 
by healthy skin are pathognomonic. Blebs are often seen in the course of 
other forms of skin disease, such as scabies, eczema, erysipelas, etc. In the 
latter malady the extensive reddened, brawny surface on which the bladder 
is seated will be a sufficient distinction. In the case of the two former 
complaints the characteristic appearances peculiar to these disorders will 
be observed. The bullous syphiloderm is distinguished from pemphigus 
by the presence of other signs of the constitutional disease. In infants 
bullous eruptions are commonly of syphilitic origin. 

The best treatment for pemphigus is arsenic. The remedy should be 
given in full doses, for a child of six years and upwards will take doses as 
large as those usually prescribed for an adult. If the irritation and dis- 
comfort of the skin and general nervous disturbance prevent sleep, opium 
is useful, more especially as in the opinion of experienced observers the 
drug has a direct curative influence upon the disease. It is especially 
serviceable in the early acute stage. The sores on the skin must be kept 
very clean and treated with some mild application, such as a lead lotion or 
zinc ointment. 

Ecthymatous pustules are very common in early life. In children of all 
ages, irritation of the skin is very apt to be followed by the development 
of large flattened pustules seated on a broad base and surrounded by a 
red zone of inflammation. Their favourite seats are the face, hands, and 
feet. The subjects of the complaint are often under-nourished, and it is 
therefore very often seen amongst the children of the poor ; but in all ranks 
of life any derangement or other cause which determines a temporary re- 
duction of strength appears to have a predisposing influence in inducing 
the eruption. Such children are usually pale and flabby, and in them 
any slight scratch may be followed by a festering sore which continues 
unhealed as long as the debility from which the patient is suffering re- 
mains unrelieved. Quinine has a specific influence in removing this 
troublesome affection. After the alkaloid has been taken for a few days or 
a week the pustules disappear, the sores heal, and the child is well. In 
all these cases the diet should be attended to and any error of feeding 
corrected. A little wine is often of service, and the child should have 
plenty of fresh air and exercise. 

A mild form of psoriasis is met with in children. The eruption usually 
occurs in the form of psoriasis guttata, the little patches being scattered 
about, not very thickly, on the trunk and limbs. The patches are usually 



DISEASES OF THE SKIN — PSORIASIS — PARASITIC. 781 

small, of a pale red tint, and are more or less scaly on the surface. They 
may be attended with slight itching. Psoriasis is seldom obstinate at this 
period of life, and usually yields without difficulty to arsenical treatment. 
Sometimes, however, the perchloride of mercury seems to be more useful 
than arsenic. As a local application the unguentum picis, or a mild 
chrysophanic acid ointment (gr. x. to the ounce of lard), may be made 
use of. 

The parasitic diseases of the skin will be described afterwards. In the 
present chapter reference may be made to the form of disease called 
alopecia areata, which is not unfrequently seen on the heads of children of 
five years of age and upwards. The disease is characterised by the loss of 
hair in spots on the scalp. At these spots the hair-bulbs atrophy, and the 
hairs, growing loose, are shed without undergoing any other alteration in 
structure. Iu-this way bald patches are formed, in which the scalp is 
completely smooth, white, and hairless. At the circumference of the 
patch the hair grows thickly as on the unaffected parts of the head. The 
number of patches may be one or more, and they may spread so as to unite 
and almost denude the head of its hair. At one time the disease was 
thought to be parasitic, but it is now allowed by most pathologists to be a 
simple atrophy of the hair-bulb ; and the hairs examined microscopically 
are found to resemble in every respect those which are cast off in the 
natural process of decay. 

The disease usually tends to spontaneous cure. The bald patches 
become eventually covered with a fine down which grows thicker and 
darker until at last the spot ceases to be recognised. In some cases the 
new hairs remain colourless and give a curiously variegated appearance to 
the head. In others the hair is only partially reproduced, so that in places 
the scalp may remain permanently bald. 

The only treatment for this condition is energetic stimulation with 
irritating applications, such as tincture of iodine, cantharides, etc. Dr. 
Thin recommends sulphur ointment. 

The above varieties of cutaneous eruption may be dismissed without 
further notice. There are, however, other forms of skin disease which 
from their frequency or importance require a more detailed description. 
The following chapters will therefore be devoted to the consideration of 
the erythemata, eczema, molluscum contagiosum, the parasitic diseases, and 
sclerema. 



CHAPTER II. 

THE ERYTHEMATA. 

In the erythematous group of skin affections the rash presents itself in the 
form of slightly raised patches of redness. These patches are of variable 
size and shape, give rise to little or no constitutional disturbance, and run 
a very rapid course. In all cases the redness shows a smooth surface, 
without scales, and disappears on pressure, returning when the pressure is 
removed. 

The varieties which will be described are : — Erythema simplex and its 
varieties ; erythema nodosum ; urticaria, and roseola. 

ERYTHEMA SIMPLEX. 

The simple variety of erythema appears to be in many cases the con- 
sequence of digestive disturbance. The rash is seen in the form of patches, 
often of some considerable size. The colour is red, bright or inclining to 
be dusky ; and the affected part is in most cases sensibly elevated from 
exudation of serum and leucocytes into the cutis and subcutaneous tissue. 
The duration of the rash is variable. In the commonest form, which is 
called erythema fugax, absorption of the exuded matter takes place very 
rapidly, and in the course of a few hours the redness has completely dis- 
appeared. This form is common in the face of a child who is fed in- 
judiciously, and suffers in consequence from fermentation and acidity. 
The patches are of very irregular shape and are imperfectly circumscribed. 
They are often accompanied by some irritation or a sense of tingling. 
There is little swelling of the skin ; indeed, the affection appears to be 
little more than a cutaneous hyperemia. When the erythema occurs in 
small raised blotches it is called erythema papulatum. The rash then con- 
sists of flattened red spots of the size of a large pin's head or a pea. Their 
margin is well defined and they are accompanied by some little irritation. 
A common seat of the eruption is the extremities, and it is rare on the 
trunk and face. The rash lasts a few days, then begins to fade, and as- 
sumes a bluish tint before it finally disappears. If there has been much 
swelling a slight desquamation is left on the skin. 

A common form of erythema in infants is that known as erythema in- 
tertrigo. In this variety the redness appears between the folds of skin in 
fat babies, and seems to be due to the friction of adjacent surfaces upon 
one another. It is seen in the neck, armpits, groins, and inner parts of 
the thighs. If the redness does not quickly disappear the surface becomes 
moist and slightly excoriated. It is then often called eczema intertrigo. 
In severe cases linear ulcerations msij be seen to occupy the bottom of the 
folds. In this stage the disorder can no longer be considered as a mere 
erythema. The ulcers have sharp, inflamed edges, and pour out a sero- 



THE ERYTHEMATA— ERYTHEMA SIMPLEX AND NODOSUM. 783 

purulent fluid in considerable quantities. A variety of erythema intertrigo 
is the superficial dermatitis which is common in children who suffer from 
diarrhoea. The irritation of the discharges from the bowel produces a 
more or less extensive erythema of the buttocks and perinseum, which, 
however, quickly disappears under treatment. 

There is one other form of erythema which requires mention, viz., that 
which is produced by the action of belladonna upon the system. This 
form of erythema resembles very closely the rash of scarlatina. In some 
children it is induced very readily, and is not to be taken as an index of 
the susceptibility of the system to the action of the drug. The readiness 
with which it is produced seems to depend more upon the sensitiveness of 
the skin than upon an}' intolerance of the drug special to the individual 
child. As a rule, young subjects can take large quantities of belladonna 
without inconvenience ; and in some cases we find the characteristic rash 
developed in a child in whom much larger doses are required to produce 
any dilatation of the pupil. 

Diagnosis. — These varieties of erythema simplex can scarcely be mis- 
taken for any more serious disease. If the patches are of some size, they 
are distinguished from erysipelas by the want of sharp outline, the lighter 
colour of the redness, the absence of any brawny sensation to the finger, 
the normal temperature, and the entire absence of constitutional disturb- 
ance. Erythema papulatum may perhaps be sometimes confounded with 
measles, but it is distinguished by the larger size of the blotches, the want 
of crescentic arrangement, the limitation of the rash to the extremities, 
and the absence of catarrhal symptoms and fever. 

Treatment. — In ordinary erythema little treatment is required. Any 
digestive disturbance must be remedied, and it is well to act upon the 
bowels with a moderate dose of rhubarb and soda. If the rash persists 
after twenty-four hours, a mild diaphoretic may be administered, such as 
liq. ammonise acetatis with spirits of chloroform, diluted with water. 

In erythema intertrigo the part should be bathed with warm water and 
carefully dried. Afterwards, a piece of lint wetted with unboiled white of 
egg, or a weak lead lotion, should be inserted between the folds of skin and 
the affection is quickly at an end. If there is constipation, a mild aperient 
— castor-oil, or rhubarb and soda — should be administered. If ulceration 
have occurred, the part should be washed frequently so as to prevent ac- 
cumulation of secretion, and the same application should be made use of. 
The erythema, which is excited by the irritation of fsecal discharges, quickly 
yields to frequent bathing with warm water, careful drying, and dusting 
with lycopodium, or with a powder composed of oxide of zinc diluted with 
three times its weight of starch. 



ERYTHEMA NODOSUM. 

Although erythema nodosum is usually included amongst the varieties 
of erythema, it is right to say that the affection is looked upon by some 
observers as a specific illness which ought properly to be classed with en- 
teric fever and the other varieties of acute specific disease. By others the 
complaint is supposed to have a distinct connection with the rheumatic 
constitution, and there is no doubt that it often attacks the subjects of 
rheumatism. 

The appearance of the rash is often preceded by pains in the limbs 
and lassitude. The spots themselves are large oval patches or swellings 



784 DISEASE IN CHILDREN. 

of a rosy red tint, and measure from one to three or four inches in their 
long diameter. They usually occupy the front of the legs and are accom- 
panied by some tenderness. At first they are hard, but after a day or two 
become softer, and may even give a sensation of semi-fluctuation to the 
finger. At the same time the colour grows more and more purple until 
it finally disappears, leaving a yellow discolouration of the skin. The 
patches are almost always present on both legs, and sometimes attack the 
forearms as well, or even other parts of the body. Their number is usually 
eight or ten. 

Each swelling goes through the changes characteristic of a bruise, 
always turning first purple, then yellow, and lasts for two or three weeks. 
The duration of the complaint is, however, often much longer ; and con- 
valescence may be considerably delayed by the appearance of successive 
crops of the nodose patches. 

A little girl, aged twelve years, was a patient in the East London Chil- 
dren's Hospital. The girl had been suffering for nine weeks from succes- 
sive crops of large red blotches which occupied the forearms and legs. 
There were also a few on the belly. They began as small red spots, which 
grew larger and became elevated and swollen. Their colour afterwards 
became purple and they then faded away like a bruise. The child was 
said to have had a similar attack two years before. She had complained 
for a fortnight of pains in the joints, and her knee had been swollen for a 
week or ten days. 

While the patient remained in the hospital various joints were in turn 
swollen and painful. After the knee had recovered the right wrist became 
affected, and later the articulation of the jaw on the right side was painful. 
Afterwards, the pain and swelling returned to the wrist. There were no 
signs of cardiac mischief ; and the temperature was always normal in the 
morning, rising at night to between 99° and 100°. She was said never to 
have had rheumatic fever. Her urine was normal. 

The child took iodide of potassium, quinine and iron without benefit, 
but improved directly the treatment was changed to drachm doses of oil 
of turpentine. Under this remedy she quickly recovered her health. The 
medicine produced little aperient action on the bowels. 

According to M. Germain See, erythema nodosum is apt to be compli- 
cated by disorders of the respiratory apparatus, especially pleurisy and 
broncho-pneumonia. 

Diagnosis. — Erythema nodosum cannot be mistaken for any other form 
of eruption. The large oval soft swellings seated upon the front of the 
legs, their tenderness on pressure, and the successive changes of colour, 
such as is characteristic of a bruise, which the swellings undergo in their 
progress to recovery, can leave little doubt as to the nature of the com- 
plaint. In purpura bruise-like patches are often seen, but the spots are 
much smaller, are not elevated, are accompanied by no tenderness, and 
are not altered in colour by pressure of the finger. Moreover, that dis- 
ease is often accompanied by haemorrhages, which are never seen in un- 
complicated erythema nodosum ; and the large bruise-like patches on the 
skin are mixed up with small deep-red petechia?. It must be remem- 
bered, however, that the two diseases may occur together, for erythema 
nodosum is an occasional complication of purpura. 

Treatment. — The patient should be kept in bed and be treated with 
quinine ; and the bowels should be kept regular with mild aperients. No 
local treatment is required unless the tenderness of the patches and the 
pains in the limbs form a subject of complaint. In that case the limbs 



THE ERYTHEMATA — URTICARIA. 785 

may be wrapped in cotton-wool. In the more chronic cases where succes- 
sive crops of swellings appear, oil of turpentine may be given, as in the 
case narrated above, in doses of one or two drachms three times a day. 
The child may have meat once a day, but no potatoes or sweets should be 
allowed while the pains continue troublesome. 



URTICARIA. 

In urticaria, or nettle-rash, the erythematous eruption appears in the 
form of wheals which produce the most distressing irritation. The com- 
plaint may be acute or chronic, and sometimes continues with varying in- 
tensity for months or even years. In the acute form, nettle-rash is a com- 
mon consequence of indigestion and acidity, and is often excited by 
special articles of food, such as shell-fish, mushrooms, etc. Insanitary 
conditions have been said to have an influence in promoting the disorder. 
Whether this be so or not, the affection is no doubt common in neglected 
children amongst the poor. In such cases it may, however, be the conse- 
quence of un cleanliness, for in subjects with delicate skins external irrita- 
tion alone will set up the complaint. Thus, the eruption may be produced 
by pediculi, and is a not uncommon complication of scabies and eczema. 
In the chronic variety nettle-rash appears to be in many cases a disorder 
of purely nervous origin ; for the eruption is often quite uninfluenced by 
modifications of diet, while it yields readily to large doses of quinine, as 
will be afterwards described. 

Symptoms. — In its common form the rash consists of a number of 
small elevations which rapidly increase in size and become white in the 
centre with a red border. These wheals are of various sizes and shapes. 
The smaller may be of the diameter of a pea ; but the larger may measure 
one or two inches in breadth and reach a considerable elevation above the 
surface. Sometimes the spots assume an elongated form like thick 
streaks ; or, again, may appear as a bright red more or less diffused 
erythematous blush. In any case they give rise to a stinging irritation 
which necessitates repeated frictions for its relief. The itching, however, 
is increased by the means used to relieve it, and the act of rubbing and 
scratching the skin produces a fresh crop of spots. The course of each 
individual wheal is very short, for the spots come and go with great rapid- 
ity. Any part of the body may be affected. The wheals may appear on 
the face, the hands and feet, the limbs, and the trunk ; and the rash is 
usually roughly symmetrical. Sometimes the eruption is not limited to 
the skin but affects the mucous membrane as well. Thus, the tongue or 
throat may suddenly swell up and produce alarming symptoms ; but the 
swelling subsides again as rapidly as it arose. 

In acute urticaria there may be well-marked constitutional symptoms. 
The rash may be preceded by fever, a furred tongue, vomiting, a quick, 
feeble pulse, and in some cases a distressing feeling of prostration. These 
symptoms are greatly relieved when the wheals appear. An acute attack 
of nettle-rash lasts from a few hours to several days. Even in this short 
time, it varies much in intensity, and is usually greatly aggravated at 
night. 

In the chronic form, the disorder continues for months. Its course is 

always very variable, and is subject to occasional remissions, so that it 

more resembles a series of acute or sub-acute attacks. In this form the 

eruption may be confined to certain localities (urticaria conferta), or may 

50 



786 DISEASE IN CHILDEEN. 

be general and affect all parts of the body indiscriminately. The wheals 
are sometimes mixed up with small papular projections, and the complaint 
is then called lichen urticatus. Another variety of the chronic complaint 
is that called by Dr. Sangster urticaria pigmentosa. The wheals are here 
very persistent, and leave yellowish pigmented spots on the skin. 

Diagnosis. — Urticaria is readily recognised. The characteristic wheals 
resembling exactly the sting of a nettle, the irritation to which they give 
rise, and the rapidity with which they come and go, leave no room for hesi- 
tation. The severe constitutional symptoms which sometimes precede the 
acute attack might conceivably arise from so many causes that no opinion 
should be hazarded until the eruption appears and explains what was ob- 
scure. The beginning of the exanthemata may be marked by similar 
phenomena, and the metastasis of mumps to the testicle or breast is occa- 
sionally preceded by like symptoms. 

Treatment. — In acute nettle-rash it is important to attend to the condi- 
tion of the digestive organs. If there be any nausea, a mild emetic, such 
as a dose of ipecacuanha wine, should be administered ; and the child 
should live plainly for a day or two, without sweets or excess of starches 
in his diet. For medicine, an aperient dose of rhubarb and soda will usu- 
ally put a speed}' end to the attack. The itching, while the eruption con- 
tinues, will be greatly relieved by dabbing the surface with a solution of 
cyanide of potassium (one drachm to the pint), or with the lotion referred 
to by Sir Thomas Watson, composed of a drachm of carbonate of ammonia 
and the same quantity of acetate of lead dissolved in eight ounces of water. 
A warm bath at bedtime in some cases is found very soothing. 

In chronic urticaria excess of fermentable food is to be avoided ; but 
the most careful dieting will often produce no beneficial effect upon the 
eruption. In the majority of cases, whatever be the cause of the persist- 
ence of the disorder, it will be found to yield readily to full doses of qui- 
nine. I have used this remedy for many years, and have not yet met with 
an instance of its failure to put an immediate end to the complaint. The 
dose should be large, and may be roughly calculated at one grain and a 
half for each year of the child's age. The remedy is administered once in 
the day, at bedtime. As an illustration of the prompt action of the alka- 
loid so administered, I may quote the case of a little girl, two years and 
ten months old, who had suffered from chronic urticaria for two years. 
The rash had varied in intensity from time to time, but had never disap- 
peared entirely ; and the child was said to be in a state of constant suffer- 
ing from the distressing itching to which it gave rise. A few powders, 
each containing three grains of quinine, were ordered ; one to be taken 
every night on going to bed. After two or three powders the rash com- 
pletely disappeared, and two years afterwards I heard that it had never 
returned. 

ROSEOLA 

Roseola, or the rose rash, is a form of erythema which is often seen in 
early life, and although a very trifling complaint, is yet on account of the 
resemblance it bears to measles of some clinical importance. 

The rash is especially common in the spring and the autumn, and this 
partiality to certain seasons of the year has given rise to the names of 
roseola sestiva and roseola autumnalis. Like the other forms of erythema 
the complaint is not contagious. It is common for one child of a family 
to be the only one attacked, although mixing freely with the others, and 



THE ERYTHEMATA— ROSEOLA. 787 

exposed to exactly the same conditions. The rash may occur several times 
in the same individual, for it is in no way self-protective ; indeed, the con- 
trary seems to be the case, and its tendency rather is to recur. 

The causes of the complaint appear to be digestive derangement and 
slight chills. The eruption occasionally complicates other diseases. Thus, 
ij may come on in the pre-emptive stage of small-pox, and is apt to occur 
in vaccinated children, and in rheumatic subjects. 

Symptoms. — The appearance of the rash is usually preceded by slight 
signs of disturbance. The child's eyes look heavy, his appetite is poor, 
his tongTie is furred, and sometimes he vomits. In rarer cases the bowels 
are slightly loose. It is said that at this time there may be slight eleva- 
tion of temperature. The pre-eruptive stage lasts usually for a few hours. 
The rash then appears as bright rose spots, which come out very rapidly, 
and soon cover large surfaces of the body. The size of these spots is very 
much that of the eruption of measles ; and sometimes, as in that disease, 
they assume a crescentic arrangement, so that except for the much brighter 
colour of the rash the general appearance of the child is that of one suf- 
fering from measles. There are, however, no catarrhal symptoms of any 
moment ; the throat is seldom reddened, and there is no cough. 

The rash lasts a few hours or a day or two, and then subsides. Usually, 
if it has appeared quickly, it fades with some suddenness ; but if it has come 
out slowly, spreading gradually over the body, it disappears in an equally 
leisurely manner. Sometimes the eruption appears in the form of small 
circular spots which remain isolated or joined irregularly ; and in some 
cases the rash bears a close resemblance to that form of scarlatina in which 
the spots remain discrete, so as to be separated by skin of healthy colour- 
ing. During the eruptive stage the temperature rarely rises above the 
normal level. 

A little girl of eight years old, the only daughter of very careful parents, 
was said to have been perfectly well without any sign of catarrh or other 
disturbance until noon on March 18th. It was then noticed that her eyes 
were heavy, but she ate her dinner as usual. In putting the child to bed 
in the evening it was found that she had some red spots on the shoulder. 
During the night she sneezed once or twice. On the morning of the fol- 
lowing day the face and body were covered with a crescentic rash which 
bore a close resemblance to the eruption of measles. It differed only in 
colour, for the tint was peculiarly bright and rosy. On the cheeks the 
rash was confluent, and it was rather papular on the jaws. There was 
very slight injection of the conj unctivse, but the fauces were not reddened. 
The child did not cough or snuffle, and there was no rhonchus or other 
abnormal sign about the lungs. A painless, movable gland, the size of a 
filbert, was felt just below the occiput. The bowels were not relaxed. 
There was no special thirst or loss of appetite. The temperature at 2 p.m. 
was 99°. Pulse, 100. 

The next day (March 20th) the rash was fading fast. The temperature 
was normal. No catarrhal symptoms. 

Sometimes the roseolous eruption comes and goes with great rapidity, 
lasting only a few hours. In such cases it usually readily recurs. The 
spots sometimes group themselves in rings. This arrangement is held to 
constitute a special variety — roseola annulata. 

Diagnosis. — Eoseola, when it assumes the crescentic form, is distin- 
guished from measles by the absence of lengthened prodromata ; by the 
colour of the rash which, instead of being yellowish-red or dull red, is of 
a bright rose tint ; by the normal or only moderately elevated temperature, 



788 DISEASE IN CHILDREN. 

and by the absence of cough and coryza. These points are well illustrated 
by the case above narrated. It is more difficult to distinguish the com- 
plaint from rotheln ; for in both disorders the eruption appears early with 
only slight prodromata, and the temperature soon becomes normal. In 
rotheln, however, there is a sensible elevation of the temperature during 
the first day or two ; the soreness of throat, which is almost absent in rose- 
ola, is a marked feature, and the eruption is dull red with none of the 
bright rosy tint of the roseolous rash. Still, in spite of these differences 
the resemblance between the two complaints is sufficiently close to make it 
probable that roseola is often called rotheln, and that the patient is sup- 
posed to have had an attack of " German measles." 

The diagnosis between roseola and scarlatina is given elsewhere (see 
page 42). 

Treatment. — The treatment required for roseola consists in keeping 
the child quiet, and attending to any digestive derangement which may be 
present. Usually no medicine is necessary. * 



CHAPTER III. 

ECZEMA. 

Eczema, one of the commonest of skin diseases in early life, and often one 
of the most obstinate, is characterised by an eruption of papules, vesicles, 
and sometimes of pustules. The rash forms more or less extensive patches 
of redness. These secrete a thin gummy fluid which dries into scales and 
crusts. The disease is accompanied by much irritation, and in severe cases 
the constant itching interferes with sleep and keeps the unfortunate pa- 
tient in a state of constant restlessness and distress. It may attack chil- 
dren of all ages, and in infants especially (eczema infantile) is apt to assume 
a sub-acute form which persists for monthsor even years with varying in- 
tensity, and is very difficult of cure. 

Causation. — Infants attacked by the disease are usually of sturdy build 
without other sign of ill-health. In such cases it is by no means easy to 
discover any cause to which the complaint can be attributed. Often one 
child of the family is alone affected, although the conditions of life appear 
to be the same in the case of the patient as in that of his more fortunate 
brothers and sisters. Sometimes, if the child is at the breast, we can de- 
tect by careful inquiry the existence of dyspepsia in the mother, or of some 
error in diet which affects the quality of her milk. In hand-fed babies ex- 
cess of starchy food may seem to be inducing an acid state of the alimen- 
tary canal which may promote and maintain the cutaneous eruption. In 
some cases a gouty or rheumatic family tendency may exist, and it appears 
extremely probable that this constitutional disposition is often to blame 
for the occurrence of eczema in young children. It has certainly seemed 
to me that infantile eczema is more common in such families than in others 
where no such proclivity exists. Again, we not unfrequently find, especially 
in scrofulous subjects, that the eczematous rash appears as a sequel of 
one of the acute specific fevers. Thus, it may come on after measles, scar- 
let fever, or small-pox. The disease is, however, often met with in cases 
where no error in management can be discovered, where the animal func- 
tions appear to be satisfactorily performed, where the child has not lately 
suffered from fever, and where no family tendency to gout or rheumatism 
can be found to prevail. 

Dentition is often supposed to be an exciting cause of the cutaneous 
affection, and no doubt a limited amount of eczema is often present in 
teething infants. But it is common for the rash to appear at the fifth or 
sixth month, before teething troubles have begun ; and the eruption not 
unfrequently lasts long after the whole crop of milk-teeth has appeared 
through the gum. 

In older children irritants to the skin, such as profuse sweating, etc., 
may produce the disease ; and at this age excess of fruit and other errors 
of diet may lead to the disorder. Scrofulous children are very liable 
to it. 



790 DISEASE IN CHILDREN. 

Symptoms. — Eczema usually begins as a bright red patch, on which a 
crop of papules very quickly appears, or the surface becomes covered with 
a number of minute, clear vesicles. There is great itching of the inflamed 
portion of skin ; and the friction to which the part is subjected very rapidly 
destroys the normal appearance of the rash. The papules are torn by the 
nails, and the vesicles also become ruptured and exude a thin fluid which 
dries into scales. The parts affected are usually those where the skin is 
delicate and soft, such as the folds of the joints, the genitals, the peri- 
nseum, the lips and cheeks, the inner sides of the thighs, and the backs of 
the legs, especially just above the ankles. It is, however, also common 
on the scalp ; but here the disease usually assumes the pustular form, and 
thick scabs are seen, under which there is a purulent fluid. In some chil- 
dren this variety is often accompanied by pediculi. 

The constitutional disturbance is seldom great ; there is rarely any 
noticeable rise of temperature, and the appetite is little impaired. In 
very acute cases, however, the burning sensation to which the inflamma- 
tion gives rise may produce great distress. The child's sleep is disturbed, 
and all his functions may be deranged by worry and want of rest. 

Several varieties of the disease are common in children. Those which 
will be described are : — Eczema simplex, eczema rubrum, eczema capitis, 
eczema tarsi, and eczema infantile. 

Eczema simplex is the commonest form of the disease. It attacks chil- 
dren behind the ears, at the orifices of the nostrils, on the cheeks, and in- 
deed on any part of the body. The rash occurs in patches of redness on 
which papules or vesicles very quickly appear, and later pustules are gen- 
erally seen. In the latter case the disease is often called eczema impetigi- 
nodes. The red rash exudes a gummy fluid, which dries into thin reddish 
or brownish crusts. When these are removed, the surface is seen to be 
red and moist, or covered with fine scales. On hairy parts, a few pustules 
are almost always seen as well. The pustules are larger than the vesicles, 
and are situated at the orifices of the hair-follicles ; for the hair can be 
seen to pass through their centre. They soon burst, and discharge their 
contents. The fluid dries and forms thick crusts, which are sometimes 
turned up at the edges. There is some infiltration of the skin at the 
affected part, and a good deal of itching and heat is complained of by the 
patient. The pustular form is most common in scrofulous subjects, but 
may occur in others who suffer from no such constitutional predisposition. 

In eczema rubrum the inflammation and redness are very great, and 
the surface of the patch is seen to be studded with deeper red points, 
which correspond to the orifices of the cutaneous follicles. The secretion 
forms thick scabs under which small excoriations are seen — the conse- 
quence of rupture of the vesicles. This variety is especially frequent at 
the folds of the joints, such as the groins, the arm-pits, and at the backs 
of the knees. It causes much itching. 

Eczema capitis occurs in the pustular (eczema impetiginodes) or the 
«caly form. The exudation to which the eruption gives rise becomes en- 
tangled in the hairs and mats them together, so that it can with difficulty 
be removed. In neglected cases it is not uncommon to find the head 
covered with a kind of cap or large scab, composed of the hair matted 
into a mass by dried exudation. This feels soft and boggy to the touch, 
from the quantity of contained purulent fluid which wells up through any 
opening in the scab. The odour is most offensive, and usually in such 
cases pediculi abound. Superficial ulcerations and small subcutaneous 
abscesses may sometimes be seen on the scalp when the crusts are re- 



ECZEMA — SYMPTOMS. 791 

moved ; and the glands of the neck and those at the back of the head 
often become inflamed and swollen. In very chronic cases the hairs may 
fall out, but they grow again when the disease is at an end. 

In infants the scaly form is the more common. The scalp may be seen 
to be covered with scabs, but exudes only a limited amount of secretion. 

A variety of eczema capitis has been described as impetigo contagiosa, 
being supposed by some authorities to be conveyed from one child to an- 
other by actual contact. There is no doubt that we often find several 
children of the same family suffering from impetigo of the scalp at the 
same time, but the contagious nature of the eruption is not universally 
recognised. It is, indeed, denied by many good observers. Dr. Tilbury 
Fox, who believed in the communicability of this form of the disease, 
states that contagious impetigo always begins as little watery heads. 

In eczema tarsi the disease affects the edges of the eyelids. This form 
is common in scrofulous children and may be combined with strumous 
ophthalmia and conjunctivitis. A number of pustules appear at the ori- 
fices of the hair-follicles. These burst quickly and form scabs. The 
eruption is attended with considerable itching and some swelling of the 
edges of the lids. The margins of the eyelids are scaly from small crusts 
which cling round the shafts of the hairs as these issue from the follicles. 
The hairs are often glued together by the secretion, and at night-time the 
edges of the eyelids are also veiy apt to stick together. When the scabs 
are removed, small ulcers are often to be detected on the skin beneath. 
Eczema tarsi is a very chronic complaint. It is often accompanied by 
much weakness of the eyes and lachrymation. If allowed to go on it 
eventually causes obliteration of the Meibomian glands and hair-follicles, 
and the eyelashes are apt to fall out, or if they remain, to grow irregularly 
and in very inconvenient directions. 

Eczema infantile is a very obstinate form of the disease. It usually ap- 
pears before the end of the sixth month, and attacks infants who in other 
respects seem to be in perfect health. It begins generally on the cheeks 
and spreads thence to the neck, chest, arms, and body generally. At first 
it is not uncommonly complicated by wheals of urticaria. In any case the 
disease is accompanied by intense itching which evidently causes the 
utmost distress to the child, and often it is necessary to secure his hands, 
so as to prevent his increasing the irritation by constant friction. Even 
when this is done he will rub his cheeks against the pillow of his cot until 
the skin is completely excoriated, and often wears the hair from the back 
of his head by constant movement of the occiput upon the pillow to relieve 
the irritation. The parts affected are intensely red, and are rough and 
scaly from drying of the secretion poured out by the ruptured vesicles, and 
pustules. In severe cases the child hardly sleeps at all on account of the 
constant itching. The course of the disease is seldom uniform ; usually it 
undergoes curious alternations of improvement and relapse. An attack of 
acute gastric catarrh will often cure the skin affection completely for a 
time, but the eruption returns as badly as ever when the gastric derange- 
ment is at an end. 

A sturdy little boy, aged five months, had suffered for a month from an 
attack of acute eczema infantile, which occupied the whole of the head, 
face, sides of the neck, and the greater part of the chest. The irritation 
was extreme. The child had worn the whole of the hair from the back of 
his head by friction of the occiput against the pillow. This infant had an 
attack of acute gastric catarrh with violent and repeated vomiting. The 
eczema at once began to fade, and in the course of three days had almost 



792 DISEASE IN CHILDREN. 

completely disappeared. Directly, however, the vomiting had ceased and 
the appetite had begun to return, the cutaneous eruption reappeared, and 
in a clay or two was as bad as before. 

This form of eczema often continues for years, and may persist through- 
out the whole of childhood. In such cases, however, the eruption gener- 
ally clears away completely from the head and face, but remains as a 
patchy rash, more or less extensively diffused over the body and limbs. 

Diagnosis. — Eczema as a rule is a disease which is readily recognised. 
The diagnostic characters of the eruption are : — A red, inflamed, and rather 
infiltrated surface which gives rise to extreme itching, and presents many 
scales or crusts, and a more or less punctated appearance, i.e., the red- 
dened skin has a dotted look from small points of a deeper red covering 
the surface of the patch. It is very important with regard to treatment to 
exclude scabies, for this parasitic eruption has often the general appear- 
ance of eczema ; indeed, a true eczema is often present on the body ex- 
cited by the irritation of the acarus. In all doubtful cases the character- 
istic furrow produced by the itch insect should be diligently searched for, 
for this, if discovered, is pathognomonic. It must be remembered that in 
young children scabies rarely affects the hands and wrists, but is more 
commonly found about the buttocks, the belly, the feet, and the ankles. 
Ecthymatous pustules seated upon the soles of the feet are very strong 
evidence in favour of scabies. 

Sometimes patches of 2)soriasis, especially if the silvery scales have been 
removed, bear a great resemblance to eczema in the dry or chronic form. 
In such cases we should carefully examine all the patches discoverable 
about the body. In eczema the patches are brighter in colour and less 
well defined at the edges, the scales are thin and loosely attached, itching 
is a marked feature, and the parts affected are usually the flexures of the 
joints and other regions where the skin is delicate and disposed to be 
moist. In psoriasis the patches are well defined and paler in colour, the 
scabs are thicker and more adherent, and itching is of moderate intensity. 
Moreover, psoriasis attacks by preference the outer parts of the limbs 
where the skin is comparatively thick and coarse. 

Syphilitic eruptions in the infant are readily distinguished from eczema 
by their more coppery tint, the absence of itching to any notable degree, 
and the presence of hoarseness, snuffling, and other well-marked signs of 
the syphilitic cachexia. 

Eczema capitis can scarcely be confounded with tinea tonsurans or favus 
by any careful observer. There are no broken or brittle hairs y such as are 
so characteristic of the former disease ; and the bright yellow cup-shaped 
crusts of favus have no resemblance to the scabs of impetigo of the scalp. 
It must be remembered, however, that a real eczema capitis may occur as 
a complication in a late stage of tinea tonsurans, but in such a case, when 
the eczema is cured, the broken hairs of the parasitic disease can be dis- 
covered on careful examination. 

I have known acute eczema in the early stage to assume a crescentic, 
slightly papular form, which has been mistaken for measles ; but the ab- 
sence of pyrexia and of cough or lachrymation will serve in such a case to 
exclude the exanthem. 

Treatment. — In cases of eczema we must not confine ourselves to local 
applications to the inflamed surface. Often the general health of the child 
will also require attention. Eczematous eruptions are common in chil- 
dren of scrofulous constitution or debilitated frame. In such patients the 
local remedies must be aided by general tonic treatment, if any permanent 



ECZEMA — TREATMENT. 793 

benefit is to be obtained. In scrofulous children the general treatment 
recommended for that cachectic state should be adopted, and if the child 
is thin and spare, cod-liver oil will be found of service. Iron-wine is also 
a Valuable remedy. 

In obstinate cases arsenic may be usefully combined with the iron, and 
as children bear arsenic well the drug can usually be given in the same 
doses as are found beneficial in the adult. There is, however, no advan- 
tage in cases of arsenic in pushing the dose to the utmost limits of toler- 
ation. It is seldom necessary to exceed five drops of Fowler's solution 
three times a day. 

If any tendency to acidity and flatulence is noticed, the alkalies are some- 
times of service, and the quantity of fermentable matter allowed in the 
diet should be restricted. Too much importance, however, need not be 
attached to the subject of diet in the treatment of eczema. If a case is 
obstinate and resists ordinary remedies, I have not found the prohibition 
of sweets and fruit of much value in promoting a cure. Other observers, 
however, seem to have met with more success. In cases of flabby (not 
plethoric) children, Mr. B. Squire advocates an almost total deprivation of 
the fat-forming elements of food. He allows milk diluted with twice its 
bulk of water ; dry toast, or dry biscuits ; lean beef or mutton with all 
the fat carefully removed ; white fish broiled ; green vegetables (but not 
potatoes, turnips, carrots, or other vegetable roots), and cooked fruit un- 
sweetened. Mr. Squire states that great improvement is seen in these 
cases within ten days of beginning this diet. 

In all cases the digestive organs should be attended to, and any de- 
rangement remedied as quickly as possible. Constipation must be re- 
lieved, looseness of the bowels arrested, and it should be our care to see 
that the animal functions generally are in good order. 

In cases of acute eczema tonic treatment is not always the best suited 
to cause the disappearance of the eruption. The disease sometimes attacks 
sturdy, florid children, with a good colour and plethoric habit. These 
cases should be treated with a mercurial purge, followed by saline laxa- 
tives to keep up a gentle action upon the bowels for several days. The 
child should take no meat, but should be put upon milk, broth, light pud- 
dings, and bread-and-butter. Again, in cases where there is an evident 
tendency to rheumatism, or a strong gouty element in the family history, 
guaiacum often has a very marked influence in curing the disease. The 
simple tincture is the best preparation ; it should be given in doses of 
twenty minims three times a day (to a child of ten years old). 

The local treatment is of great importance in the treatment of eczema. 
When the eruption is very acute, stimulating ointments should not be used, 
but the part should be kept moist with a simple water-dressing, or be 
bathed frequently with bran-water made by pouring boiling water upon 
bran and allowing it to cool. Dr. K. Liveing recommends the applica- 
tion to the affected surface of a powder composed of three drachms each 
of oxide of zinc and starch, and thirty grains of camphor. Over this is to 
be placed a warm linseed-meal poultice. 

In a later stage alkaline warm baths are useful. Dr. Buckley recom- 
mends that for this purpose the carbonates of soda and potash and the 
biborate of soda be used ; two to four teaspoonfuls of each to the gallon of 
water. To these two to four teaspoonfuls of dry starch are added. This 
bath should be used without soap, the child being merely soaked and 
bathed in the medicated water. After ten minutes or so he is removed, 
dried without friction, and then well dusted over the body with lycopo- 



794 DISEASE IN CHILDREN. 

dium powder. Much washing is to be forbidden in cases of acute eczema, 
as it is said to injure the process of repair. Dr. Buckley only allows it 
when the accumulation of exuded matter prevents the ointments from 
reaching the diseased surface. 

A useful form of bath is made by medicating the water with Wright's 
liq. carbonis deturgens in the proportion of two drachms to the gallon. 
This can be given at first every night for half an hour ; afterwards on 
alternate nights. Local patches of eczema are often benefited and in 
many cases quickly cured by keeping the part constantly moist with a 
lotion composed of two drachms of the liq. carbonis deturgens to ten 
ounces of water. To be effectual, however, the moistened rags in contact 
with the affected surface should never be allowed to get dry. 

Zinc and lead are two of the most valued applications for eczematous 
patches. In the moist variety a salve composed of oxide of zinc and the 
solution of the subacetate of lead — a drachm of each to the ounce of vaseline 
—is very useful. In the dry, scaly form of the rash this ointment is made 
more efficacious by the addition of twenty to thirty grains of the ammonio- 
chloride of mercury and a drachm of the liq. carbonis deturgens. If 
itching be very distressing, the following application, taken from the 
pharmacopoeia of University College Hospital, is of great service : — 

I£ . Calamine (zinci carb. ) gr. xl. 

Zinci oxidi gr. xxx. 

Glycerini - l\[ xx. 

Aquam rosge ad. § j. 

M. Sig. — To be painted with a brush on the affected part. 

In eczema capitis the crusts must be first carefully removed. This is 
best done by covering them at night with a thick layer of lard and placing 
over this a large linseed-meal poultice. In the morning the softened 
crusts can be picked off with forceps or bathed away with warm water. 
When completely cleansed the scalp must be anointed with ammonio- 
chloride of mercury ointment diluted with an equal proportion of lard ; 
or we may use the salve composed of oxide of zinc and subacetate of lead 
already referred to. Children who have this form of impetiginous eczema 
in a severe degree are usually of strumous constitution and require tonic 
treatment. In obstinate cases of eczema of the scalp the disease can often 
be cured by tarry applications. Half an ounce of common tar, oil of cade, 
or oil of birch (olei rusci) may be added to two ounces of glycerine of 
starch. This can be painted over the head twice a day. In very chronic 
cases one thorough application of undiluted liquid tar will sometimes pro- 
duce a complete cure of the disease. 

Eczema of the nostrils is usually cured very quickly. The crusts must 
be first removed from the nostrils by softening them with an oiled plug 
and afterwards bathing with warm water. Unguentum hydrargyri am- 
monio-chloridi can then be applied freely to the interior of the nostril with 
a folded morsel of linen rag or lint. 

In eczema tarsi it is often necessary to pull out the eyelashes, and in 
obstinate cases the operation is almost always necessary. The scabs must 
be carefully removed with fine forceps or the head of a large pin, and the 
edges of the lids be afterwards smeared with any of the ointments which 
have been recommended. A mild mercurial salve, perhaps, answers the 
best. 

Eczema infantile is often a very obstinate complaint, and from the dis- 



ECZEMA— TREATMENT. 795 

tress it occasions to the infant and through him to his mother or nurse, 
whose sleep is necessarily broken by the wakefulness of her charge, is one 
upon which it is important to make some immediate impression. When 
the disease is very acute and the skin red and intensely irritable, a rapid 
improvement is produced by large doses of quinine. I was led to employ 
the remedy in these cases from noticing its striking influence upon chronic 
urticaria in young children. In eczema a dose of two grains given at bed- 
time to a child of six or eight months old, and repeated every second 
night, reduces, in a remarkable manner, the general redness, soothes the ir- 
ritation, and consequently greatly relieves the child's distress. He begins 
to sleep better at night, and in the daytime is less irritable and fractious. 
Per chloride of mercury, given internally in small doses, is also a valuable 
remedy. A child of eight months old may take ten or fifteen drops of the 
solution (P. B.) three times a day, and the eruption often seems to im- 
prove greatly under its use. Thirty or forty drops of the infusion of 
rhubarb with a few grains of bicarbonate of soda, given regularly two or 
three times a day, will often also be followed by considerable benefit. 

As in older children, the simple tincture of gnaiacum is a remedy 
which sometimes produces very rapid and decided improvement. I have 
seen the fiery redness of the general surface fade, and the itching almost 
entirely cease under a week's use of this remedy given in doses of ten 
minims three times a day. When it succeeds, guaiacum seems to take all 
the acuteness out of the complaint, and reduces the eruption to a common 
vesiculo -pustular rash which yields readily to ordinary applications. 

The alkaline bath recommended by Dr. Buckley, and the bath medi- 
cated with the liq. carbonis deturgens (see page 794), are both very use- 
ful. They, the latter especially, have great influence in relieving the itch- 
ing, and the calamine and zinc application already referred to may be 
used with the same object. Too frequent washing of the infant is bad in 
these cases, and the mother should be cautioned against disturbing the 
treatment by the too energetic use of soap and water. 

Vaccination of the child is said in some obstinate cases to produce a 
complete cure of the disease, and many observers have borne testimony to 
the occasional value of this method of treatment. In successful cases the 
eczematous rash clears away completely in from one to four weeks after 
the operation. 

A method of treatment by covering the affected surface with some im- 
permeable material, such as caoutchouc cloth, so as completely to exclude 
the air, has been found useful in many cases. According to E. Bessener 
this plan is especially applicable to cases of eczema of the scalp where 
there is much secretion. The india-rubber sheeting must be adapted accu- 
rately to the head, so as to fit like a skull-cap, and must be kept scrupu- 
lously clean, being regularly removed for washing and drying. By this 
means speedy improvement is said to be effected even in obstinate cases, 
so that the eruption will quickly yield to the ordinary ointments. 



CHAPTEK IV. 

MOLLUSCUM CONTAGIOSUM. 

Molluscum contagiosum is a disease more common in childhood than in 
after-life. It is often seen in London children, especially amongst the 
poor, but appears to be less prevalent in country districts, or even in other 
large towns in England. The contagious nature of the disease is now well 
established. It may be communicated by one child to another, or by a 
sucking infant to its mother's breast, and Dr. R. Liveing states that he has 
seen nine children of the same school all affected witli molluscum at the 
same time. In addition to being contagious the disease may also arise 
spontaneously. 

Morbid Anatomy. — The exact seat of molluscum contagiosum is still a 
matter of debate. Many observers hold the view that the little tumours 
have their seat in the sebaceous glands of the skin. This was long ago 
denied by Virchow, and after this authority others have supported the 
opinion that the bodies consist of a morbid growth of the cells of the cutis. 
Sections of the tumours show that some are simple cyst-like bodies, others 
are lobulated and surrounded by a fibrous capsule from which fine septa 
pass between the lobules. The subject has been lately investigated anew 
by Dr. Sangster, who concludes, as a result of his observations, that mol- 
luscum contagiosum is a disease of the epidermis in which three layers take 
part. The external portion is formed by the cells of the rete, for on care- 
ful vertical section of the earliest specimens procurable the rete is seen in 
direct continuity with the lobular expansions of the new growth. The 
cells probably undergo simple hyperplasia, and those placed at the border 
are elongated and vertical. Next to these is a granular layer composed of 
polygonal cells more or less infiltrated with fat-globules. In the centre 
are roundish bodies, translucent and watery-looking, which are called 
"molluscum corpuscles." All these are arranged in masses which lie in 
the meshes of a granular reticulum. The tumour is covered by the more 
superficial layer of the corium, and at its base is a network of fine ves- 
sels. 

Symptoms. — Molluscum contagiosum appears in the form of small, 
white, hard, translucent swellings which gradually increase in size until 
they reach the dimensions of a pea, or even a nut. Their form is circular, 
with a flattened top, and at this part is seen a minute depression, which is 
supposed by those who recognise the sebaceous origin of the tumours to 
be the mouth of the sebaceous cyst. The smaller growths are usually 
sessile ; the larger are pedunculated. A milky-looking thickish juice can 
be squeezed out of the central depression, especially if a puncture has been 
previously made with the point of a lancet. 

There is no itching or uneasiness connected with the growths in their 
ordinary state, but sometimes one will inflame and be converted into a 
pustule. When left alone the tumours gradually dry up, leaving some 



MOLLUSCUM CONTAGIOSUM— DIAGNOSIS— TKEATMENT. 797 

thickening at their site. The older ones are usually succeeded by a fresh 
crop. 

Their seat is usually the skin of the face, the eyelids, or the neck, but 
they may be also seen on the chest, abdomen, genitals, and inner part of 
the thighs. 

Diagnosis. — These tumours must not be confounded with the mollus- 
cum fibrosum, which is altogether a different disease. These are small 
bodies of solid, somewhat gelatinous structure, and consist, according to 
Kokitansky, of a protrusion of the corium, " which is pushed forwards by 
accumulation of young, gelatinous connective tissue in one of its deepest 
meshes." They have no umbilication like the contagious molluscum, and 
no milky juice can be obtained from them by pressure. 

Treatment. — The smaller tumours must be touched with nitric acid or 
other strong caustic. The larger must be divided with a lancet and the 
contents squeezed out. A little caustic can be afterwards applied. 



CHAPTEE Y. 

THE PARASITIC DISEASES. 

The varieties of parasitic disease of the skin which will be described are : — 
Scabies, due to the irritation of the acarus scabiei or the itch-insect ; and 
certain vegetable parasitic fungi, viz., tinea tonsurans and tinea favosa. 

SCABIES. 

The symptoms to which the acarus scabiei gives rise are due to the irrita- 
tion produced by<»the insect as it burrows in the skin. The female acarus 
works its way into the epidermis and forms a narrow tunnel called " cuni- 
culus." The intense itching thus occasioned forces the child to relieve him- 
self by scratching ; and the consequences are seen in the wheals, papules, 
vesicles, and even pustules which in a typical case are mixed up together in 
a manner which is very characteristic of the complaint. 

The cuniculus or furrow appears as a whitish curved line, which when 
newly formed may be easily overlooked ; and in children, especially in in- 
fants, who are well tended and frequently washed, may escape notice alto- 
gether unless narrowly searched for. In hospital patients they are readily 
discovered as they become darker and more distinct from small specks 
of dirt. The furrow is about the eighth of an inch in length, but may be 
longer, and to the naked eye closely resembles the scratch of a pin. Viewed 
with a lens it has a dotted look, and sometimes at one extremity a small 
white object can be detected, which is the female insect. With care this 
may be extracted with the point of a pin. 

In infants the furrows are rarely seen on the wrist and between the fin- 
gers as they are in older children and in the adult. In these young sub- 
jects they must be searched for on the abdomen, the waist, the buttocks, 
round the ankles, and on the soles of the feet ; but in babies in well-to-do 
families, where cleanliness is properly attended to, the sign may elude the 
closest inspection. In young children after the age of infancy they are 
also usually seated on the buttocks, feet, and ankles. It is only in children 
of five or six years and upwards that they are often to be detected between 
the fingers. The scalp and face are rarely attacked. 

The itching to which the presence of this parasite gives rise is of the 
most distressing character, and at night may be extreme. The child will 
be seen to dig his nails into the skin in his efforts to obtain relief. As a 
consequence we find reddened linear scars from small furrows made by 
the nails ; and as another result of the violent scratching, can usually dis- 
cover small papules, often excoriated and tipped with a minute crust of 
dried blood, little vesicles, and even large deep-seated pustules. These lat- 
ter are often seen on the soles of the feet. In very delicate subjects a real 
eczema may be set up either by the irritation of the nails or of the applica- 



THE PARASITIC DISEASES — SCABIES — TINEA TONSURANS. 799 

tions used for the destruction of the parasite ; and large wheals of urticaria 
are far from uncommon. 

Diagnosis. — The simultaneous appearance of a variety of eruptions on 
the body of an infant is a very suspicious feature ; and if with a lens we 
can succeed in discovering the characteristic furrow, no doubt can remain 
as to the nature of the complaint. In the case of an infant, the hands of 
the mother or nurse will be always found to be affected. Therefore in every 
case of doubt a careful inspection should be made of the hands of the at- 
tendant. In searching for the furrow in young children attention should 
be always especially directed to the buttocks, abdomen, and the soles of the 
feet. In older children the furrows may be seen between the fingers and 
on the wrist as in the adult ; and as at this age, especially in boys, cleanliness 
of these parts is often neglected, the cuniculus seldom fails to be discovered. 

Treatment. — Scabies can only be cured by local treatment which kills the 
parasitic insect, and the favourite and most efficacious remedy is the applica- 
tion of sulphur ointment to the skin. It must be remembered that in chil- 
dren, in infants especially, the skin is delicate and sensitive to irritants. 
Therefore, while care is taken to make effectual use of the salve so that the 
acarus may be destroyed, we should avoid maintaining the cutaneous irrita- 
tion by too prolonged or too zealous application of the ointment. At night- 
time the child should be first thoroughly washed over the whole body with 
a strong soap, and be then well bathed with warm water, so as completely 
to soften the skin and lay open such furrows as may be present by destroy- 
ing their roofs. He should then be well dried, and an ointment made of 
half a drachm of precipitated sulphur to the ounce of lard must be rubbed 
into the skin of the whole body except, of course, the head. It is important 
that the salve be rubbed into the skin and not merely smeared over the 
surface. In the morning the skin should be again thoroughly washed. 
This one application will cure the disease in most children. It is advisable, 
however, to rub a little of the ointment into the parts which seem to have 
been especially affected for two or three nights longer. We should then 
pause to watch the effect of the treatment. Itching often continues for 
some time after the parasites have been destroyed, as a consequence of the 
various forms of eruption set up by the acarus. In cases where it is doubt- 
ful whether the disease be cured or not, Dr. B. Li vein g recommends an 
ointment made with the balsam of Peru ( 3 ij. to the ounce of lard). 

If it be thought desirable to disguise the sulphur in the ordinary 
ointment, this can be done by a drop of creasote or oil of bergamot. Dr. 
Liveing prefers the precipitated to the sublimed sulphur, as being in a 
finer powder, and less irritating to the skin. 

Instead of sulphur, an ointment may be used of liquid styrax (one 
part) and lard (two parts), or of powdered stavesacre and lard ( 3 ij. to 
the ounce) ; but these are distinctly inferior to the sulphur. Ointments 
containing carbolic acid have also been made use of. It is advisable to 
well scald the underclothing of the patient, and after recovery to bake the 
outer garments, so as to insure the destruction of stray insects. 



TINEA TONSURANS. 

Tinea tonsurans is peculiarly a disease of early life. This affection is 
practically confined to children, and in the form of ringworm of the scalp 
is one of the most obstinate and contagious of complaints. The disease is 
due to the presence of a fungus — the tricophyton tonsurans — which grows 



800 DISEASE IN CHILDREN. 

in the internal root-sheath within the follicle, and the fine mycelium fila- 
ments penetrate into the hair between the fibres. These filaments are 
composed of cylindrical, tube-like bodies united in chains. At the surface 
of the hair the spores of the tricophyton are collected into little globular 
masses called conidia, and in very old-standing cases these are also seen 
to fill almost the whole thickness of the hair. As a consequence of the 
presence of the parasitic fungus the hairs are greatly thickened ; their 
colour changes to a dull gray tint, and their brittleness causes them to 
break off short at a point immediately above the follicle out of which 
they issue. The fungus is seen not only in the substance of the hair, and 
coating their shafts, but also as a more or less continuous layer on the sur- 
face of the scalp. Through this covering the free ends of the stubbly hairs 
can be seen as black points. Later, as the parasitic matter accumulates, 
the stumps of hair become completely ensheathed in the mycelium coat- 
ing so that their situation is only shown by a projection of the surface of 
the layer. Bazin has compared the appearance thus produced to that of a 
surface covered with hoar-frost. 

In very old-standing cases, acute inflammation may be set up in the 
hair-follicles. This may lead to complete destruction of the hairs, so that 
the part of the scalp affected remains partially bald. 

Symptoms. — On the scalp ringworm is seen in more or less circular 
patches. These in the earliest stage are slightly raised above the surface, 
and cause considerable itching. The hairs are not broken off, and have 
almost a natural appearance ; but they will be found to be very brittle, so 
that they generally break if an attempt is made to extract them. As the 
disease proceeds the patches become distinctly circumscribed, and of a 
pale fawn or slate-gray colour. Their surface is covered by a thick scurf 
formed of epithelial scales mixed with the fungoid growth. This scurf 
gives a frosted appearance to the patch, and adheres to the shafts of the 
hairs as these emerge from the follicles. The patches are not entirely 
covered by the short bristly hairs, for in many places these have fallen 
out, leaving the surface bare. Those which remain are short and twisted. 
They look as if cut off about a line or two above the surface of the scalp ; 
and are thickened, dull in colour, and sometimes loose in their sockets. 
If the scurf has accumulated to a great thickness, the ends of the hairs 
may be completely concealed from view. 

The number of patches existing at the same time varies. Sometimes 
they are very numerous ; indeed, in certain cases, the disease takes on a 
diffuse form, in which little groups of scaly patches with bristly stumps of 
hairs are seen scattered over the surface of the head. 

"When the tinea is seated on the skin of the body it is called tinea cir- 
cinata. This is also a very common form of the disease, and is generally 
found on the face and neck, although it may occupy any part of the body 
or limbs. It is seen as a slightly elevated, roundish patch, of a light red 
colour, and of the size of a small pea. This begins to extend at its edges, 
and as the circumference spreads, the central part fades and becomes less 
prominent, so that the circular patch is converted into a ring which con- 
tinues to enlarge. With a lens the surface affected is seen to be covered 
with branny scales ; and fine vesicles are noticed at the margins. If two 
adjacent rings happen to touch one another, morbid action at the point of 
contact undergoes no further extension. In this way curiously irregular 
shapes are often produced. In the central part of the ring the skin 
although of comparatively healthy appearance, has yet a yellowish tint, 
and a roughened look from small scales. These spots cause a great deal 



THE PAEASITIC DISEASES — TINEA TONSURANS. 801 

of irritation, and the fungus is no doubt often conveyed by the child's 
nails from the body to the scalp. 

The general health of children affected with ringworm is often unsatis- 
factory ; and the complaint seems to attack, by preference, weakly and 
scrofulous subjects. The latter, especially, have seemed to me to be pecu- 
liarly prone to the disorder. 

Diagnosis. — In cases of ringworm of the scalp the chief diagnostic 
point is the appearance of little rounded, scaly patches, on the surface 01 
which the hairs are thick, dull in colour, and broken short off just above 
the follicles. If one of these short hairs be removed with a pair of fine 
forceps, and placed with a drop of liq. potassse under the microscope, the 
characteristic masses of spores and mycelium filaments will be readily 
distinguished. If the hair-stump be allowed to soak in the drop of potash 
solution for an hour or two before inspection, the parasitic fungus will be 
more readily detected. 

At an earlier period than this the complaint is less easy to recognise. 
It is, however, of great importance to detect the affection in its early stage. 
It often happens that when one child of a family suffers from tinea tonsu- 
rans one of his brothers or sisters is brought for examination, because he 
has been noticed to have some irritation of the scalp. If, in such a case, 
ringworm be present, we shall find one or two small rounded patches, 
roughened with fine scales ; and shall notice that although no stumpy 
hairs are to be seen, and the hairs have a natural appearance, the}' are yet 
unusually brittle, so that they break off when an attempt is made to pull 
them out with the forceps. From the first, therefore, in ringworm the 
hairs are brittle ; and at an early period of the disease the circular shape 
of the patch on the scalp, and the brittleness of the hairs growing upon it, 
are the two points of chief diagnostic value. 

An important question, and one upon which our opinion is often re- 
quired, is that of whether in a given case the child is well. To settle this 
point correctly requires a very careful examination of the scalp. If any 
diseased stumps of hairs remain the complaint is not entirely eradicated. 
The child is therefore still a source of infection to others, and is him- 
self liable to a relapse. Even a bald patch from which the hairs have been 
carefully extracted is not to be considered well. Often after an interval 
the stumps will shoot up again, the diseased bulb of the hair having been 
left in the follicle. It is not until the part lately the seat of the ringworm 
is seen to be covered with a fine downy growth, in which no single stump 
of the old crop can be detected, that it can be said, confidently, to be free 
from disease. 

In some cases a difficulty is occasioned by the presence of eczema 
which has invaded the scalp towards the end of an attack of ringworm. 
When this happens the evidences of ringworm may be quite concealed by 
the complication. "YVe must therefore withhold a positive opinion until 
the eczema has been cured. 

Tinea circinata is distinguished by its annular shape, and in cases of 
doubt by examination under the microscope of a scraping from the skin 
of the patch. The spot selected for this purpose should be a part of the 
ring towards the inner margin. This should be gently scraped, and the 
scaly matter removed is to be placed under the microscope, with a drop 
of liq. potassge. The jointed mycelium will then be recognised, and a few 
spores will usually be seen. 

Treatment. — In cases of ringworm of the scalp, the measures to be 
adopted, and the probable efficacy of the treatment, vary considerably, ac- 
51 



802 DISEASE m CHILDREN. 

cording as the disease is of recent or remote origin. Eecent cases can 
usually be quickly cured, but chronic cases resist treatment with singular 
obstinacy. 

Treatment will also vary according to the age of the patient. Ring- 
worm can only be cured by local applications, and the measures to be 
adopted consist of the use of two classes of remedies, viz., those which irri- 
tate the skin and destroy the fungus, by exciting inflammation in the fol- 
licle, and those which kill the parasite without producing inflammation. 
Of these two classes the first is not suitable to very young patients. Blis- 
ters and violent caustics are dangerous remedies in the case of infants ; 
and on account of the pain they excite are not to be used carelessly even 
on older subjects. 

In infants and young children it will be usually sufficient to wash the 
head thoroughly with soap and hot water every night, and after careful 
drying to paint the patch with tincture of iodine. After a few days the 
application can be changed to the unguentum hydrargyri ammonio-chloridi 
(P. B.) diluted with an equal proportion of lard ; or equal parts of this 
salve and the unguentum sulphuris may be made use of. Either of these 
must be well rubbed into the affected parts of the scalp. Another useful 
application is the glycerine of carbolic acid diluted with a third part of 
glycerine. This may be painted on the patch with a stiff brush, or rubbed 
in with a piece of sponge tied to the end of a pencil. 

In older children the treatment varies according to the acuteness or 
chronicity of the disease. In either case it is important to keep the hair 
cut closely to the scalp in the neighbourhood of the patches. The disease 
is most infectious in its earlier stages, and becomes much less liable to be 
communicated wiien undergoing treatment. Of course care will be taken 
that towels, pillows, etc., used for the patient are not shared by the other 
children. As an additional precaution Dr. B. Liveing recommends that 
the carbolised glycerine, pure or diluted with an equal proportion of gly- 
cerine, should be well rubbed into the scalp every morning. 

In a recent case, if the diseased patch be of small extent, it should be 
blistered by the liq. epispasticus. Afterwards, when the sore has healed, 
the oleate of mercury ointment (five per cent.) should be well rubbed 
into the patch every night. It is useful to vary the application every 
week or ten days. Therefore, in addition to the preceding, a salve com- 
posed of sulphur ointment (half an ounce) with white precipitate (twenty 
grains) may be used, or the ointment 1 recommended by Mr. Alder Smith, 
made by adding one part each of pure carbolic acid and unguentum hydrar- 
gyri nitratis to four parts of the unguentum sulphuris, may be employed. 
A favourite remedy in recent cases is the preparation known as " Coster's 
paste," made by adding two drachms of iodine to one ounce of the colour- 
less oil of tar. Mr. Morant Baker prefers to substitute creasote for the 
oil of tar. The application is to be painted thickly on the patch with a 
camel's-hair brush. 

If under treatment the patches become very sore, so that the rubbing 
in of the ointments causes too great pain, Mr. Alder Smith recommends 
simply smearing the surface of the patch with the carbolic ointment dur- 
ing the day and poulticing with bread-and-water every night. These 
measures are often followed by a rapid cure. The penetration of the 

1 In mixing this ointment no heat is to be applied. The two salves are first to be 
amalgamated, and the carbolic acid is then to be rubbed in. The strength of this ap- 
plication can be varied according to the age of the child by increasing the proportion 
of carbolic acid and nitrate of mercury. 



THE PARASITIC DISEASES — TINEA TONSURANS. 803 

remedy into the hair-follicles is aided by previous removal of the hair- 
stumps. This epilation is done with a forceps made for the purpose. 
Care must, however, be taken in extracting the hair, as on account of its 
brittleness it is very apt to break off, leaving the bulb still in the follicle. 
It is also important to pick or wash off the fine crusts of scurf which, as 
long as they remain, are greatly in the way of efficient treatment. If the 
scab is difficult to remove it should be well greased with cold cream or 
saturated with olive-oil, and poulticed. It then becomes quite soft and 
can be easily picked off. 

In old-standing cases the above remedies are still of service, and careful 
epilation should be practised. Sometimes the long duration of the dis- 
order seems to be due to ignorance or neglect ; the remedies not having 
been applied effectually, or care not having been taken to remove the scurf 
before applying the salve. The energetic use of oleate of mercury oint- 
ment (five per cent.) is recommended by Mr. Alder Smith as a useful 
remedy even in chronic cases. After careful washing of the head the 
oleate, freshly made, is well rubbed into the whole scalp with a sponge 
mop. In the use of this application it is well to refrain from charging the 
mop too liberally with the remedy, lest the ointment run down the face 
and neck. At night, too, a linen cap should be worn on the head ; and a 
thin towel is often necessary, applied as a turban, to prevent irritation of 
the face by the oleate. Any smearing of the skin elsewhere than on the 
scalp with the salve will produce a copious eruption of small pustules and 
much swelling. Every night the general application is to be repeated ; 
in the morning the inunction is to be limited to the diseased patches. 
While this plan of treatment is being carried out the head must be washed 
only once a fortnight ; but scabs or yellowish incrustations must be fre- 
quently removed by the forceps. If the oleate set up inflammation in the 
patch a speedy cure is usually effected. 

The beneficial effects observed as a consequence of inflammation set up 
in the patch has led to the employment of special irritants with the express 
view of producing this result. Mr. Alder Smith, who has devoted much 
attention to this method of treatment, states that very long-standing cases 
can sometimes be cured by this means. He selects a small patch and ap- 
plies to it croton-oil in moderate quantity with a small stiff camel's-hair 
brush. After a few hours he applies a poultice and keeps it on the head 
all night. If severe inflammation has not ensued by the next day the 
process is repeated, and sometimes three or four applications may be 
needed. The object is to set up artificial " kerion," i.e., to produce a 
swollen, boggy, freely-discharging surface from inflammatory swelling and 
effusion in the tissues around the follicles. When kerion is produced no 
more croton-oil need be applied, but the part must be frequently fomented 
with warm water. After a few days the stumpy hairs become loose and 
fall out, and when the inflammation has subsided a smooth, shining, 
slightly-raised red surface is left " utterly destitute of all hairs and stumps 
and practically well." Eventually, the spot becomes again covered by new 
healthy hairs. 

This plan of treatment is only admissible in the older children, and 
the application should be confined to a limited surface if the patch is a 
large one. While in progress the carbolic glycerine or oleate should still 
be applied to other parts of the scalp. By this means Mr. Alder Smith 
states that he has had successful results in apparently incurable cases, 
and has never seen any internal irritation or erysipelas set up by the use 
of this powerful irritant 



804 DISEASE IN CHILDREN. 

In obstinate cases of ringworm of the scalp constitutional treatment is 
also required. Often the patients are anaemic, scrofulous, or ill-nourished 
subjects, and cod-liver oil and tonics will be of service in improving their 
general health. 

Ringworm of the body [tinea circinata) is quickly cured by the applica- 
tion of a strong irritant. I am in the habit of painting the ring lightly 
with glacial acetic acid. This application causes some smarting for a short 
time, but usually cures the disorder at once. Sometimes a second appli- 
cation to parts of the ring is required after five or six days. Other appli- 
cations which may be used are the strong tincture of iodine, and a solu- 
tion of nitrate of silver ( 3 j- to the ounce). 



TINEA FAVOSA. 

Tinea favosa, or favus, is much less common in England than the pre- 
ceding. Like it it is a contagious disease, and is most frequently seen in 
scrofulous or neglected and badly-fed children. It is said to be common 
in some countries in mice and rats, and instances have been known in 
which the disease has been conveyed from these animals to the children of 
the family. 

Favus is due to the presence of a cryptogam — the achorion Schoenleinii. 
The mycelium and spores of this fungus may be seen without difficulty if 
a portion of the crust be put under the microscope, moistened with a drop 
of liq. potassae. 

Symptoms. — Like tinea tonsurans, favus may occur on any part of the 
body, but is usually met with on the head. It begins in small scaly 
patches which cause much itching. In this early stage the disease bears a 
close resemblance to the ordinary ringworm, especially as the hairs grow- 
ing on the diseased spot quickly lose their lustre and get dull in colour. 
They do not, however, as in ringworm, become brittle, so that there is no 
difiiculty in pulling them out with the forceps. 

After a time small yellow crusts of about the size of a pin's head appear 
on the patch round the hairs. These crusts are at first convex, but after- 
wards as they enlarge become cup-shaped. They are of a sulphur-yellow 
colour, and vary from a split pea to a mass of the diameter of half an inch. 
Usually one or two hairs pass through the centre. At first the favus crusts 
are placed singly, but they may afterwards become confluent, so as to form 
irregular-shaped masses, more or less extensive, and without the character- 
istic cup-shaped depression. The smell of the head covered by the crusts 
is very unpleasant and somewhat resembles that of mice. On the removal 
of a favus crust a depression is seen which is red and may be ulcerated. 
This, after a few days, disappears and the surface becomes again covered by 
a new crop of cup-shaped crusts. When the crusts become detached and 
fall off spontaneously the skin is merely seen to be stained of a dark red 
or violet colour. As the disease goes on the hairs lose their natural tint, 
and grow loose in their sockets so as to be pulled out with ease. Their 
shafts are found on inspection to be irregular in their diameter at differ- 
ent points, and their roots are atrophied. They become fewer in number, 
and if the disease persists may disappear altogether, leaving the part com- 
pletely bald. 

On the body favus, like tinea tonsurans, forms rings, but these always 
remain small, seldom exceeding half an inch in diameter, and have not the 
characteristics of tinea circinata. In other respects they bear a close re- 



THE PARASITIC DISEASES— TINEA FAVOSA. 805 

semblance to that disease. Afterwards, however, the characteristic crusts 
make their appearance at the edges and on the surface of the rings. 

Diagnosis. — When the disease is well developed on the scalp, the cup- 
shaped crusts, and their sulphur-yellow colour are very characteristic. It 
is in the early stage before the crusts appear, and in the later stage when 
the crusts have lost their peculiar features, that the disease is liable to be 
mistaken. In the early stage the round, itching, scaly patches closely 
resemble common ringworm, but a distinction is supplied by the want 
of brittleness of the hairs in favus. In this disease the hairs can be pulled 
out of their follicles with ease, while in tinea tonsurans, if an attempt be 
made to extract the hair, it almost invariably snaps short off close to the 
scalp. Li the later stage when the crusts have lost their distinctive char- 
acter, especially if, as often happens, they have become complicated with a 
secondary eczematous eruption, the diagnosis is again less obvious, but the 
history of the case, and a careful microscopic examination of the crusts, 
which reveals the mycelium and spores of the cryptogam, will indicate the 
nature of the case. 

Treatment.— The crusts must be removed by saturating them with olive- 
oil, and then poulticing, or by constantly applying a strong sulphurous 
acid lotion under a cap of oiled silk. When the scalp is quite denuded of 
crusts and scabs the hair must be cut close to the skull, and steps can 
then be taken to remove all the hairs from the diseased surface. This is a 
work requiring much time, trouble, and patience ; for each hah' must be 
carefully extracted by the forceps, taking care to pull in the direction in 
which the hair is growing. When this has been done, the special remedy 
must be well rubbed into the scalp. Any of the applications recommended 
for tinea tonsurans may be made use of, but one of the most effectual is 
the oleate of mercury ointment (five per cent.). This must be used care- 
fully and with precaution that the ointment does not run over the face. 

If the child be badly nourished or anaemic, strengthening medicines 
and good nourishing food will be of service in aiding his recovery. 



CHAPTER VI. 

SCLEREMA. 

Sclerema, a disease which consists in a hardening of the cutaneous cellular 
tissue sometimes met with in young infants, is rarely observed in England, 
but appears to be less uncommon on the continent of Europe. The affec- 
tion was first completely described by Underwood and Denman. Shortly 
afterwards Andry of Paris applied Underwood's description to a totally 
different lesion. This observer had frequently noticed at the Hospice des 
Enfants-Trouves of Paris a condition in which the surface of the body be- 
comes indurated as a consequence of subcutaneous oedema. This disorder 
answered in many respects to Underwood's description, so that by a not 
unnatural confusion Andry adopted Underwood's term for his own account 
of oedema of the new-born infant. After his time the error, thus begun, 
was perpetuated by successive writers until Parrot, to whose labours the 
pathology of infantile disease is so much indebted, showed clearly in his 
work on " Athrepsie " that two very different conditions had been hitherto 
confounded under the same title. In the present chapter the true sclerema 
will be first described ; afterwards a short account will be given of " oedema 
of the new-born infant." 

TRUE SCLEREMA. 

True sclerema (induration of the cutaneous cellular tissue) is confined 
to new-born infants. This lesion is not to be confounded with the sclero- 
derma which attacks older children and adults. It occurs only, according 
to Parrot, in feeble infants and those wasted by bad feeding and unwhole- 
some conditions generally. According to Underwood it appears as a fea- 
ture of the last stage of atrophy from digestive derangements. 

Morbid Anatomy. — The lesion consists in a curiously condensed state 
of the skin. This tissue is thinned as if from compression of the several 
layers. The rete Malpighii and corium have sensibly lost thickness, and 
the coils of the former layer can hardly be detected, so intimately are they 
amalgamated into a compact mass. In the adipose layer the fat-lobules 
are atrophied ; their globules are wasted ; and the connective-tissue bands 
are more numerous and thicker than in the normal state. According to 
Underwood, the induration of the cellular tissue may reach the sheaths of 
the muscles and even affect their fibres. There is never any subcutaneous 
oedema in the true disease. The blood-vessels, especially those of the pap- 
illse, are so narrowed that their lumen is obliterated. These pathological 
changes form a very distinct condition — different on the one hand from 
oedema of the new-born, and on the other from scleroderma of older chil- 
dren and adults. They are the consequence, according to Parrot, of de- 
siccation of the tegumentary tissues owing to the draining away of fluid by 
the copious watery discharges from the bowels. There must, however, be 



SCLEREMA — MORBID ANATOMY — SYMPTOMS. 807 

some other cause for the pathological change, for in this country it is com- 
mon enough to find young infants reduced by bad feeding and profuse 
watery diarrhoea to a state of extreme emaciation ; but sclerema is a lesion 
so rare that when discovered it is regarded as a clinical curiosity. 

A form of sclerema called adipose sclerema is sometimes met with. 
This is different pathologically from the preceding. It is due to a solidifi- 
cation during life of the subcutaneous fat. According to Dr. Langer the 
melting point of infant's fat is 113° Fahr., or a higher- point than the 
temperature of the body ; while adult fat becomes perfectly fluid at a tem- 
perature of 96.8° Fahr. Hence, in the healthy child during life, a large 
proportion of its fat is not quite fluid but merely soft. If, from any reason, 
such as collapse, or the rapid withdrawal of heat which sometimes occurs in 
young infants as a consequence of depressing illness, the temperature of 
the body falls to 89.6°, this degree of cooling, according to Dr. Langer, is 
sufiicient completely to solidify all the fat in the panniculus adiposus. 

Symptoms.— The more special symptoms of sclerema are preceded by 
great impairment of nutrition and rapid wasting. The induration begins 
to be noticed at the end of the first week of life, or on the ninth or tenth 
day, or in some cases in the course of the second month. According to 
some writers it is especially in infants born fairly healthy and robust, and 
whose nutrition has become rapidly impaired that the cutaneous symptom 
is most likely to occur. 

The induration generally begins in the lower limbs and spreads thence 
to the loins, the back, the chest, and eventually to the whole body, face 
included. In some cases the face is said to be attacked early, and the in- 
duration to spread from this part to the body. The affected skin, com- 
pletely losing its natural softness and suppleness, becomes hard and un- 
yielding, and pressure with the finger meets a resistance like that of horn 
or hardened leather. The folds and lines of the skin disappear, and partly 
from rigidity, partly from its close connection with the underlying tissues, 
it can no longer be pinched up between the finger and thumb. 

When the whole body is thus affected the induration prevents any 
bending of the joints, so that the limbs are stretched stiffly out, and it is 
even said that the body may be supported in a horizontal position in the 
air by a hand placed under the loins. The rigidity of the face, especially 
of the lips and cheeks, makes sucking impossible, although the induration 
of this part is usually less advanced than that of other regions of the body. 
But for this, and for the little feeble respiratory movement of the abdomen 
and chest, the infant might be thought to be dead. Indeed, the tightly- 
compressed lips, the closed eyes, the mask-like face, the immobility of the 
frame, and the peculiar coldness of the surface, resemble death more 
nearly than life. 

The lowness of the temperature is one of the striking features of this 
condition. The diminution of heat of the skin gives a marked sensation 
of coldness to the hand, and even in the rectum the temperature may fall 
far below the normal level. The body is not only cold, but seems incapa- 
ble of being warmed ; and even the occurrence of pneumonia has no ap- 
preciable effect in raising the temperature. The pulse and respiration fall 
in frequency. The former may be as low as sixty in the minute, the latter 
fourteen. The respiratory movements are hampered and feeble, and the 
cry is weak and almost inaudible. 

The course of the disease is very rapid. The induration proceeds 
apace. By the third day, according to Underwood, the skin has become 
intimately adherent to the tissues beneath. By the fourth the induration 



808 DISEASE IN CHILDREN. 

has become general over the body. The child usually dies on the seventh 
day or soon afterwards. 



(EDEMA OF NEW-BORN CHILDREN. 

(Edema of new-born children is also a very rare disease in this coun- 
try. The subcutaneous tissue is infiltrated with yellowish serosity which 
permeates between the adipose lobules, but never passes between the 
muscles or sinks below the level of the subcutaneous tissue. The fat is 
converted into a yellowish brown mass. In some cases there is congenital 
atelectasis. 

Symptoms. — The disease begins, according to Valleix, before the third 
day of life, and the infants affected are almost always prematurely born or 
feeble. At first the child is noticed to be drowsy, and its skin is then 
found to be livid and very cold to the touch. The oedema is first noticed 
in the feet and thence spreads upwards to the thighs. The hands are next 
attacked, and later the oedema appears in the genitals and the back. There 
are, however, exceptions to this order. Valleix states that he has known 
the oedema to appear first in the cheek ; and sometimes the hands begin 
to swell directly after the feet have been attacked. The swelling is usually 
greater on one side than on the other, and tends always to sink to that on 
which the infant is lying. The affected parts pit with difficulty on press- 
ure, but are swollen, and feel doughy and hard. The skin at first has a 
purple colour, especially at the extremities, and before death may have a 
jaundiced hue. It does not become adherent to the parts beneath as in 
the case of sclerema, and there is not the same stiffness of the joints. The 
temperature is low and may fall to 86°. It is little raised by the external 
application of warmth to the body. The child lies in a drowsy apathetic 
state, and scarcely attempts to cry. The pulse is small and very feeble ; 
the breathing slow and interrupted ; convulsions may come on, and the 
prostration may be increased by a watery diarrhoea. Death may be hast- 
ened by intercurrent attacks of bronchitis, pneumonia, collapse of the 
lung, gastric or intestinal catarrh, etc. In some of the cases parenchyma- 
tous nephritis and albuminuria have been observed. 

Diagnosis. — The two diseases, sclerema and oedema of the new-born, are 
very dissimilar, although they appear to be produced by much the same 
conditions, and certain symptoms are common to both. In each case we 
find a lowering of the temperature, a fall in the pulse and respiration, and 
a rigidity of the surface of the body. In each case the weakness is pro- 
found; and the infant lies motionless, refuses to suck, and more nearly 
resembles a dead child than a living one. There are, however, important 
differences in the two diseases. In sclerema the skin is tense and hard, 
and adheres firmly to the tissues beneath it ; the joints are extended and 
stiff, and the whole body is rigid as if petrified or frozen. The firmness 
and rigidity increase day by day, and death occurs at the end of the first 
or the beginning of the second week. 

In oedema the parts affected are firm and swollen, but can be made to 
pit on deep pressure. The swelling is partial and is most marked on the 
side upon which the child is lying. The skin can be moved over the parts 
beneath it ; and the stiffness of the joints is but little pronounced, never 
prevailing, as in sclerema, to a sufficient degree to resist the force of 
gravity. The disease, also, is of longer duration than is the case with 
sclerema, and although very dangerous on account of the weakness of the 



SCLEEEMA— (EDEMA OF NEW-BORN CHILDREN. 809 

child, is not invariably fatal. The two diseases may exist together, or 
sclerema may succeed to oedema, as in a case reported by Parrot. 

Treatment. — In cases of true sclerema little can be done. On account 
of the impossibility of sucking, the infant should be fed with white wine 
whey by means of the syringe feeder (see page 15). By this means a 
sufficient quantity of food can be introduced at intervals into the back of 
the throat when it is readily swallowed. In order to maintain the warmth 
of the body, the child should be wrapped in cotton-wool, and should be 
surrounded with hot water-bottles. 

In the oedema of new-born infants the child, if he cannot suck, may be 
fed with the syringe as directed above. He should take white wine whey, 
milk and barley-water, and other varieties of food suitable to this period 
of life (see page 603). Warmth must be maintained as in the former case, 
and gentle frictions to the surface of the body are of service in helping to 
disperse the oedema. 



INDEX 



Abdomen, large, in infancy, 12 

large, in rickets, 141 

retracted, in tubercular meningitis, 13, 
359 
Abdominal muscles, rheumatism of. 159 

wall in tubercular meningitis, 358 
Abscesses in scarlet fever, 40 

in small pox, 59 

subcutaneous, in scrofula, 177 
Aconite in treatment of quinsy, 588 
Acorion Schoenleinii, 804 
Acorn coffee in treatment of scrofula, 188 
Acute rickets, 142 
Adenia (see Lymphadenoma), 220 
iEgophony as a sign of effusion, 405 
Aglobulosis, 231 
Ague, 147 

anaemia in, 149 

cachexia of, 149 

causation of, 147 

cold stage of, 148 

congestion of liver in, 148 
treatment of, 151 

diagnosis of, 149 

diarrhoea in, 149 

duration of, 149 

hot stage of, 148 

in cachectic children, 149 

morbid anatomy of, 147 

oedema in, 149 

prognosis in, 150 

quinine, hypodermic injection of, in, 
151 

splenic enlargement in, 148 

sweating stage of, 148 

symptoms of, 148 

temperature in, 148, 149 

treatment of, 151 

types of, 148 

urine in, 149 
Albuminous retinitis in chronic Bright's 

disease, 755 
Albuminuria a serious symptom in congen- 
ital heart disease, 542 

from embolism of kidney, 158 

in acute tuberculosis, 195 

in ague, 149 

in Bright's disease, acute, 39 
chronic, 755 



Albuminuria in diphtheria, 95 

in infantile tetanus, 310 

in measles, 24 

in membranous croup, 89, 414 

in pneumonia, croupous, 426 

in scurvy, 257 

in stridulous laryngitis, 412 

in thrush, bad cases of, 574 

intermittent, 746 

scarlatinous, 39 

treatment of, 46 
Air-passages, diseases of, 399 

foreign body in (see Foreign Body in 
Air-tubes). 526 

obstruction of, 519 
Alcohol, value of. 18 
Alopecia areata, 781 

treatment of, 781 
Alum in whooping-cough, 125 
Amyl, nitrite of, in convulsions, 285 

in epilepsy, 293 
Amyloid degeneration of organs in empy- 
ema, 450 

in inherited syphilis, 211 

in pulmonary cirrhosis, 477 

liver (see Liver, the Amyloid), 731 
Anaemia, 229 

aperients in treatment of, 234 

arsenic in treatment of, 235 

breathlessness in, 232 

causation of, 230 

cold water packing in treatment of, 
235 

complexion in, 232 

diagnosis of, 233 

diet in, 234 

epistaxis in, 233 

headache in, 233 

idiopathic, 233 

in ague, 149 

in amyloid liver, 732 

in chronic Bright's disease, 755 

in valvular disease of heart, 547 

in empyema, 447 

in fibroid induration of lung, 477 

in gastric catarrh, 231, 611 

in gastro-intestinal haemorrhage, 656 

in haemophilia, 244 

in hemorrhagic purpura, 250 



812 



INDEX. 



Ansemia in hypertrophied spleen, 238 

in inherited syphilis, 210, 231 

in leucocythemia, 217 

in lymphadenoma, 224 

iron in treatment of, 234 

morbid anatomy of, 231 

murmurs in, 233 

palpitation in, 232 

petechiae in, 233 

prognosis in, 234 

readily produced in the child, 229 

symptoms of, 232 

treatment of, 234 
Aneurism in early life, cause of, 323, 549 

rupture of, on brain, 322 
case of, 327 
Angina (see Pharyngitis), 576 

scarlatinous, 35, 37 
Anthelmintics, 712 
Antimony in treatment of bronchitis, 488 

of inflammatory diarrhoea, 639 
Antiseptic sprays in diphtheria, 104 

in gangrene of lung, 500 

in pulmonary phthisis, 518 

in whooping-cough, 126 
Aorta and pulmonary artery, transposition 
of, 536 

duration of life in, 541 
Aperients, abuse of, 19 

for habitual constipation, 621 
Aperients, value of, in treatment of anae- 
mia, 234 

of acute Bright's disease, 46 

of chronic Bright's disease, 761 

of quinsy, 589 

of uraemia, 46 

of valvular disease of heart, 553 
Aphasia in early life, significance of, 263 
Aphonia, hysterical, 409 
Apoplexy, cerebral (see Cerebral Haemor- 
rhage), 322 
Aromatics, value of, in artificial feeding, 

605 
Arsenic as a prophylactic in scarlet fever, 
43 

in ague, 152 

in anaemia, 235 

in chorea, 305 

in lymphadenoma, 227 

in pemphigus, 780 

tolerance of children for, 19, 306 
Artificial feeding of children, various foods 

for, 604, 606 
Artificial feeding of infants, 603 

common cause of failure in, 606 

method of conducting, 603 

necessity of vigilance in, 608 

preparation of milk for, 604, 606 

value of milk in, 596 
Artificial human milk, 606 
Ascaris lumbricoides, 705 

description of, 705 

migrations of, 706 

symptoms of, 709 

treatment of, 712 
Ascites, 700 



Ascites, causation of, 700 

diagnosis of, 702 

fluctuation in, 701 

in acute peritonitis, 687 

in anaemia, 232 

in atrophic cirrhosis of liver, 701, 728 

in congenital heart disease, 539 

in tubercular peritonitis, 695 

prognosis in, 703 

symptoms of, 700 

treatment of, 704 
Asphyxia, local, 167 
Asthenic measles, 24 
Asthma, bronchial, 520 

causation of, 520 

diagnosis of, 521 

symptoms of, 521 

treatment of, 524 
Asthmatic attacks from enlarged bronchial 

glands, 182, 522 
Atelectasis, congenital, 461 

artificial respiration in, 464 

causation of, 461 

diagnosis of, 463 

diet in, 464 

drowsiness in, 462 

emetics in treatment of, 464 

hot bath in treatment of, 464 

lividity in, 462 

morbid anatomy of, 461 

physical signs of, 462 

prognosis in, 463 

respiratory movements in, 462 

stimulants in treatment of, 464 

symptoms of, 462 

temperature in, 462 

treatment of, 463 

warmth, importance of, in, 464 
Atelectasis, post-natal, 465 

causation of, 465 

convulsions in, 457 

diagnosis of, 469 

diet in, 472 

in infants, 467 

in older children, 468 

lividity in, 467 

morbid anatomy of, 466 

physical signs of, 467 

prognosis in, 471 

respirations in, 467 

sudden death from, 467 

symptoms of, 467 

temperature in, 467 

treatment of, 471 
Atrophy in infantile syphilis, 211 

infantile (see Infantile Atrophy), 596 
Atrophy of muscle in acute infantile spinal 
paralysis, 375 

in chorea, 303 

in haemorrhage into cord, 377 

in pseudo-hypertrophic paralysis, 386 

in rickets, 134 
Atrophy of third nerve from pressure, 226 

of tissues in thrush, 572 

period of, in infantile spinal paralysis, 
375 



IXDEX. 



813 



Atrophy, progressive muscular, rare in 

childhood, 387 
Atropia in treatment of whooping-cough, 

124 
Attitude, clinical value of, 8 
Attitudes in spical caries, 178 
Auscultation of chest, 403 
of skull in rickets, 138 

Bacillus of whooping-cough, 115 

the tubercle, 191, 506, 510 
Back, pain in, in caries of spine, 178 

in cerebro -spinal fever, 69 

in small-pox, 56 
Back, stiffness of, in caries of spine, 178 
Backward children, 395 
Bacteria in umbilical phlebitis, 717 
Balsam of Peru as an application for 

scabies, 799 
Barley-water in the hand-feeding of in- 
fants, 604 
Bath, the cold, 16 

the hot, 16 

the mustard, 16 
Baths for eczema, 793 

the therapentic value of, 16 
Belladonna rash, 783 

tolerance of, in childhood, 19 
Bile-ducts, malformation of, 716 
Bilharzia haematobia, 747 
Bladder, atony of, in enteric fever, 71 

stone in, symptoms of, 767 

tuberculosis of, 193 
diagnosis of, 199 
symptoms of, 197 
Blindness in cerebro-spinal fever, 71 
Blood, clotting of, in heart, 98, 550 

extravasations of, in scurvy, 254 

in anaemia, 229, 232 

in leucocythemia, 217 

in lymphadenoma, 222 

in purpura, 248 

in stools (see Melaena) 

poisoning in diphtheria, 95 

vomiting of (see Hgematemesis) 
Blotches, purpuric, in cerebro- spinal fever. 
69, 70 

in lymphadenoma, 224 

in purpura, 248 

in scurvy, 256 

in spontaneous gangrene, 168 
Bone, arrest of growth of, in infantile 
spinal paralysis, 373 

in rickets, 140 
Bones, perverted ossification of, in rickets, 
132 

scrofulous disease of, 178 

syphilitic disease of, 206 
age most liable to, 208 
Bothriocephalus latus, 707 
Bowel, perforation of, in enteric fever, 82 

treatment of, 87 
Bowel, prolapse of, from straining at stool, 

619 
Bowels, obstruction of, causes of, 668 
Bowels, ulceration of, 660 



Bowels, aperients in, danger of, 664 

astringent injections in treatment of, 
667 

constipation in, 661 

diagnosis of, 664 

diarrhoea in, 662 

diet in, 666 

haemorrhage from, 662 

malted bread in treatment of, 666 

morbid anatomy of, 660 

natrition in, 662 

prognosis in, 665 

raw meat treatment of, QQQ 

stools in, 662 

symptoms of, 661 

temperature in, 662 

treatment of, 66Q 
Brain, congestion of, 316 

causation of, 316 

connection of, with convulsions, 317 

diagnosis of, 319 

morbid anatomy of, 317 

prognosis in, 320 

stupor in, 318 

symptoms of, 318 

temperature in, 319 

treatment of, 321 
Brain, haemorrhage into (see Cerebral 

Haemorrhage), 322 
Brain, tumour of (see Cerebral Tumour), 

330 
Breast-milk, analysis of, 597 
Breath, offensive, in cases of constipation, 
619 

of fibroid induration of lung, 477 

of gangrene of lung, 499 

of gangrenuos stomatitis, 568 

of ulcerative stomatitis, 565 
Breathing, amphoric, value of, 404 

cavernous, value of, 404 

Cheyne-Stokes type of, 264 

hollow, in cases of enlarged bronctiial 
glands, 182 

hollow, in cases of enlarged tonsils, 
588 

hollow, value of, 404 

irregular in tubercular meningitis, 359 
Breathing, stertorous, in membranous 
croup, 95 

in oedema of glottis. 408 

in retro-pharyngeal abscess, 592 

in scald of larynx, 407 

in stridulous laryngitis. 412 

in suppuration about larynx, 420 

in tubercular laryngitis. 416 

in warty growths on larynx, 417 
Breathlessness (see Dyspnoea) 

in auaemia, 232 

in heart disease. 547 
Breath-sounds, conduction of, by chest- 
wall, 404 

suppressed from impaction of foreigu 
body in air-tubes, 528 

weak, clinical value of, 404 
Bright's disease, acute. 39 

convulsions in, 39 



814 



INDEX. 



Bright' s disease, acute, symptoms of, 39 

treatmeat of, 46 

urine in, 39 
Bright's disease, chronic, 752 

anaemia in, 755 

causation of, 752 

diagnosis of. 759 

dropsy in, 754 

morbid anatomy of, 753 

prognosis in, 760 

symptoms of, 754 

treatment of, 760 
Bromide salts in convulsions, 284 

in epilepsy, 292 

in laryngismus stridulus, 273 

in whooping-cough, 125, 284 

rash, 292 
Bronchi, acute dilatation of, 435, 439 

diagnosis of, 441 
Bronchi, chronic dilatation of, 474 

diagnosis of, 514 
Bronchial glands, enlargement of, 178 

asthmatic attacks in, 182, 522 

diagnosis of, 185, 522 

dyspnoea in, 182, 522 

earliest sign of, 183 

epistaxis in, 181 

hoarseness in, 182 

oedema of face in, 181 

physical signs of, 182 

prognosis in, 186 

signs of pressure from, 181 

symptoms of, 180 

terminations of, 181 

treatment of, 188 

venous hum in, 182 
Bronchiectasis, acute, 435, 439 

chronic, 474 

physical signs of, 476 
Bronchitis, acute, 481 

capillary, 483 

causation of, 481 

counter-irritation in, 486 

diagnosis of, 485 

expectorants in treatment of, 487 

morbid anatomy of, 482 

physical signs of, 486 

prognosis in, 486 

pulse in, 484 

symptoms of, 483 

temperature in, 483 

treatment of, 486 
Bronchitis, chronic, 484 

symptoms of, 484 

treatment of, 489 
Bronchitis, tuberculous, 196 

diagnosis of, 199 

Calabar bean, effect on pulse of, 312 
in treatment of tetanus, 313 
of tetany, 276 
Calculi, renal, 763 

Calculus impacted in urethra causing re- 
tention, 748 
of kidney (see Kidney, Calculus of), 
763 



Cancrum oris (see Stomatitis, Gangren- 
ous), 567 
Cardiac dropsy, 547 

treatment of, 553 
Caries of spine, symptoms of, 178 
Carpo-pedal contractions in laryngismus 
stridulus, 269 

in stridulous laryngitis, 413 
Caseation of glands, 173 
Casein of cow's milk, 597 

of goat's milk, 597 

of human milk, 597 
Castor-oil in treatment of dysentery, 651 

of inflammatory diarrhoea, 638 
Cataract, congenital, a cause of nystag- 
mus, 261 

in idiocy, 394 
Catarrh, gastric (see Gastric Catarrh), 601 

intestinal (see Diarrhoea), 624 

laryngeal (see Laryngitis), 406 

proneness to, in rickets, 142 
in scrofula, 176 
Catarrh, pulmonary, 481 

causation of, 481 

in teething, 559 

recurring attacks of, 483 

symptoms of, 482 

treatment of, 486 
Catarrhal pneumonia (see Pneumonia, 

Catarrhal), 434 
Cauterisation in treatment of gangrenous 

stomatitis, 570 
Cephalalgia (see Headache) 
Cerebellar tumour, symptoms of, 337 
Cerebral arteries, syphilitic degeneration 
of, 211 

congestion (see Brain, Congestion of), 
316 

flush in tubercular meningitis, 359 
Cerebral haemorrhage, 322 

causation of, 322 

diagnosis of, 328 

from congestion of brain, 328 
from meningitis. 325 
from tumour of brain, 328 

from aneurism of a cerebral artery, 
323 

in a case of purpura baemorrhngica, 251 

morbid anatomy of, 323 

prognosis in, 329 

symptoms of, 326 

temperature in, 324 

treatment of, 329 
Cerebral embolism, case of, 548 

murmur in rickets, 138 

paralysis, diagnosis of, 377 

pneumonia, 364 

rheumatism, 156, 159 
Cerebral sinuses, thrombosis of, 351, 650 

diagnosis of, 353 

symptoms of, 351 
Cerebral symptoms in croupous pneu- 
monia, 353, 364, 382 

without cerebral disease, 2 
Cerebral tumour, 330 

convulsions in, 332 



INDEX. 



815 



Cerebral tumour, diagnosis of, 337 

headache in, 332 

loss of special sense in, 332 

morbid anatomy of, 330 

nature of, 339 

optic neuritis in, 338 

paralysis in, 332 

prognosis in, 339 

symptoms of, 331 

treatment of, 339 

tremours in, 333 

varieties of, 331 

vomiting in, 332 
Cerebritis (see Encephalitis), 351 
Cerebro-spinal fever, 68 

blindness from, 71 

causation of, 68 

coma in, 69 

convulsions in, 70 

deafness from, 71 

diagnosis of, 72 

duration of, 72 

eruption in, 70 

hallucinations in, 70 

in infants, 72 

invasion of, 69 

morbid anatomy of, 68 

paralysis in, 70 

prognosis of, 73 

pulse in, 71 

pupils in, 71 

retraction of head in, 69 

rigidity of joints in, 69 

symptoms of, 69 

temperature in, 70 

treatment of, 73 

urine in, 71 

vomiting in, 70 
Chest, auscultation of, 403 

deficient movement of, 401 

distortion of, in rickets, 139 

examination of, in children, 399 

flattened, the, 400 

infra-mammary depression of, 400 

movements of, in respiration, 400 

pain in, from foreign body in air- tubes, 
528 

pain in, a sign of spinal caries, 178 

percussion of, 402 

pigeon-breasted, the, 400 

pterygoid, the, 400 

resonance of, in childhood, 402 
Chest, retraction of, in cirrhosis of lung, 
476 

in inspiration, 400 

in pleurisy, 450 
Chest, shape of, in chronic bronchitis, 485 

in chronic tubercular phthisis, 508 

in congenital heart disease, 538 

in emphysema, 493 
Chest wall, resistance of, to percussion, 

403 
Chicken-pox, diagnosis of, 49 

duration of, 49 

gangrenous, 49 

symptoms of, 48 



Chicken-pox, temperature in, 48 

treatment of, 50 
Childhood, convalescence in, 5 

definition of, 5 

diathetic tendencies in, 4 

functional disorders in, 3 

proneness to anaemia in, 229 

sudden death in, 5, 270. 374 
Children, forced feeding of, 15 
Chills, susceptibility to, in early life, 4 

in rickets, 142 

in scrofula, 176 
Chloral, in treatment of chronic albumin- 
uria, 46 

of convulsions, 284 

of laryngismus stridulus, 273 
Chlorate of potash in ulcerative stomati- 
tis, 566 
Chlorides, urinary, diminished in croupous 

pneumonia, 426 
Chorea, 299 

a cause of valvular disease of heart, 
544 

arsenic in treatment of, 305 

atrophy and contraction of muscle 
after, 303 

causation of, 299 

cold douche in treatment of, 305 

course of, •604 

death from, 304 

diagnosis of-, 304 

ether spray in treatment of, 306 

forced feeding in, 306 

heart murmurs in, 303 

massage in treatment of, 306 

mental state in, 303 

muscular weakness in, 303 

pathology of, 300 

prognosis in, 304 

symptoms of, 301 

temperature in, 303 

treatment of, 305 

urine in, 303 
Circulation, changes in, at birth, 536 

foetal, at term, 535 

in brain, 316 
Cirrhosis of liver (see Liver, Cirrhosis of), 
726 

of lung (see -Fibroid Induration of 
Lung), 473 
Club-foot from infantile spinal paralysis, 
376 

from intra- uterine convulsions, 277 
Cod-liver oil, precautions in giving, 18 
Cold douche in treatment of chorea, 305 

of malignant scarlet fever, 45 

of rickets, 146 

of scrofula, 188 . 

precautions in giving, 17 
Cold sponging in enteric fever, 86 

in inflammatory diarrhoea, 637 

in laryngismus stridulus, 272 
Cold water packing for anaemia, 235 
Colic, cry of, 9 

diagnosis of, 674 

in dysentery, 647 



816 



INDEX. 



Colic, in infants, 619 

in purpura haemorrhagica, 249 

in spontaneous gangrene, 168 

renal, 766 

treatment of simple, 622 
Collapse, general, in intussusception, 671 

of lung (see Atelectasis), 461 
Colon, severe catarrh of, 631 

character of stools in, 635 

symptoms of, 632 

treatment of, 6^9 
Colour, blue, in cyanosis, cause of, 538 
Coma (see Stupor) 
Complexion in amyloid disease of liver, 732 

in anaemia, 232 

in atrophic cirrhosis of liver, 727 

in congenital atelectasis, 462 
heart disease, 538 

in difficult digestion, 7 

in empyema, 447 

in gastric catarrh, 231, 611 

in gastro-intestinal haemorrhage, 656 

in haemophilia, 244 

in haemorrhagic purpura, 250 

in healthy infants, 7 

in hypertrophied spleen, 238 

in inherited syphilis, 7, 210 

in leucocythemia, 217 

in lymphadenoma, 234 

in pleurisy, 446 

in rickets, 141 

in scurvy, 256 

in tuberculosis, acute, 195 

pasty, from constipation, 619 
Conduction of sounds in chest, 404 
Congenital cataract, 261 

rickets, 135 

syphilis (see Syphilis, Inherited), 202 
Conidia of trichophyton tonsurans, 800 
Constipation, 617 

after chronic dysentery, 650 

after rheumatism, 618 

aperients for, 621 

causation of, 617 

diagnosis of, 620 

diet for, 633 

impaction of faeces in, 620 

in chronic Bright's disease, 758 

in enteric fever, 77 

in haemophilia, 246 

in intussusception, 670 

in peritonitis, acute, 687 
tubercular, 696 

in peri-typhlitis, 680 

in renal inadequacy, 758 

in tubercular meningitis, 358 

in typhlitis, 679 

in ulceration of bowels, 662 

pepsin in treatment of, 622 

symptoms of, in infants, 619 
in older children, 619 

treatment of, 621 

value of enemata in treatment of, 622 
Consumption, pulmonary (see Phthisis, 

Pulmonary), 502 
Convalescence from acute disease, 5 



Convalescence from chronic disease, 5 

often slow in enteric fever, 82 
Convulsions, 277 

at onset of acute disease, 3 

bromides in treatment of, 284 

causation of, 277 

chloral in treatment of, 284 

common in infancy, 277 

complicating laryngismus, 268 

consequences of, 280 

description of, 279 

diagnosis of. 281 

during dentition, 278, 560 

causes of, 560 
from anaemia of brain, 251, 278 
from arachnoid haemorrhage, 324 
from blood-poisoning in malignant 

scarlet fever, 37 
from cerebral disease, 263 
from collapse of lung, 278, 467 
from earache, 278, 348 
from lead given medicinally. 279 
from peripheral irritation, 278 
from uraemia, 282 

treatment of, 46 
imbecility after, 281 
in acute tuberculosis, 196 
in cerebral haemorrhage, 324 
in cerebro-spinal fever, 69 
in congenital malformation of heart, 

540 
in encephalitis, 351 
in enteric fever, 79 
in erysipelas. 111 
in infantile spinal paralysis, 373 
in intussusception, 671 
in leucocythemia, 218 
in lymphadenoma, 227 
in measles, 22, 25 
in melaena neonatorum, 656 
in purulent meningitis, 349 
in rickets, 142 
in scarlet fever, 34 
in spontaneous gangrene, 170 
in tubercular meningitis, 360 
in tumour of brain, 332 
in umbilical phlebitis, 719 
in whooping cough, 119 

diagnosis of, 123 

treatment of, 127 
internal (see Laryngismus Stridulus?), 

267 
nitrite of amyl in treatment of, 285 
paralysis after, 280 
prognosis in, 283 
rare as a consequence of indigestion, 

601 
rare in wasted infants, 3, 277 
reflex, frequent in rickets, 142 
stupor after, 281 
treatment of, 284 
Cornea, ulceration of, in facial paralysis, 
369 
in small-pox, 59 

treatment of, 64 
Coryza, scarlatinous, 38 



INDEX. 



817 



Coryza, scarlatinous, treatment of, 64 
Coryza, syphilitic, 209 
Cough, characters of, in bronchial asthma, 
521 

in bronchitis, acute, 483 
chronic, 485 

in catarrhal pneumonia, 437 

in chronic enlargement of tonsils, 588 

in chronic laryngitis, 408 

in cirrhosis of lung, 476 

in croupous pneumonia, 424 

in enlargement of bronchial glands, 
182 

in follicular pharyngitis, 578 

in foreign body in air-tubes, 528 

in gangrene of lung, 498 

in measles, 24 

in membranous croup, 95, 413 

in oedema of glottis, 408 

in phthisis, acute, 506 

chronic pneumonic, 509 
tubercular, 511 

in retro-pharyngeal abscess, 592 

in stridulous laryngitis, 412 

in tubercular laryngitis, 416 

in valvular disease of heart, 547 

in warty growths on larynx, 41 7 

in whooping-cough, 116 
Counter-irritation, value of, 17 
Cow-pox, 51 
Cranio tabes in inherited syphilis, 208 

in rickets, 138 
Cretinism, 392 

absence of thyroid gland in, 393 

affinity of, with congenital rickets, 135 

causation of, 392 

defective si^ht in, 394 

diagnosis of, 396 

early ossification of skull in, 393 

fatty masses above collar-bones in, 393 

hearing normally acute in, 394 

large size of head in, 394 

Virchow's views of, 393 
Crisis in croupous pneumonia, 429 
Croton chloral in treatment of whooping- 
cough, 126 
Croup, false (see Stridulous Laryngitis), 411 
Croup, membranous, 95 

apncea in, 99 

death in, 96 

diagnosis of, 101 

diagnosis from foreign body in air- 
tubes, 101, 533 
from oedema of glottis, 490 
from retro-pharyngeal abscess, 

594 
from stridulous laryngitis, 413 

duration of , 96 

dyspnoea in, 96 

nature of, 88 

prognosis in, 102 

symptoms of, 95 

tracheotomy in, 105 

treatment of, 105 
Croupous pneumonia (see Pneumonia, 
Croupous), 422 
52 



Cry in earache, 9 

Cry in infancy, absence of, 10 

significance of, 8 

varieties of, 8 
Cry in sclerema, 807 
Cyanosis (see Heart Disease, Congenital), 

535 
Cystitis, tubercular, 197 

Dactylitis, syphilitic, 207 

diagnosis of, 212 
Deafness a cause of late talking, 395 

from enlarged tonsils, 587 

from follicular pharyngitis, 579 

from quinsy, 585 

in caries of petrous bone, 369 

in cerebro-spinal fever, 71 

in enteric fever, 79 

in inherited syphilis, 211 

in measles, 23 

in mumps, 66 

in scrofula, 177 
Death, sudden, in infancy, 5, 270, 374 

in pleurisy, 458 
Deformities in rickets, 137 
Deglutition in diphtheria, 100 
Delirium, causes of, 262 

early, with fever, in croupous pneu- 
monia, 262, 425, 430 

evidence of, in infants, 262 

from debility, 262 

from disseminated emboli of brain, 158 

in acute infantile spinal paralysis, 373 
peritonitis, 687 
rheumatism, 159 

in cerebro-spinal fever, 70 

in chorea, 303 

in croupous pneumonia, 262, 425, 430 

in debility, 262 

in diphtheria, 95, 97 

in dysentery a fatal sign, 651 

in enteric fever, 77, 79 

in infants, 262 

in measles, 24 

in mumps, 66 

in purulent meningitis, 350 

in scarlet fever, 36, 43 

in small-pox, 60 

in tubercular meningitis, 359 

significance of, 262 
Dentition (see Teething), 555 
Desquamation in erysipelas, 112"' 

in erythema papulatum, 782 

in measles, 23 
Desquamation in scarlet fever, 36 

earliest sign of, 42 

postponed, 36, 42 

treatment of, 47 
Diagnosis of ague, 146 

of air-passages, foreign body in, 523 

of alopecia areata,. 781 

of anaamia, 233 

of ascites, 702 

of asthma, bronchial, 523 

of atelectasis, congenital, 463 
post-natal, 469 



818 



INDEX. 



Diagnosis of atrophy, infantile, 602 
of bowels, ulceration of, 664 
of brain, congestion of, 319 

haemorrhage into, 328 

tumour of, 337 
of Bright' s disease, chronic, 759 
of bronchial asthma, 523 

glands, enlargement of, 185, 522 
of bronchiectasis, 514 
of bronchitis, 485 
of calculus of kidney, 767 
of cancrum oris, 569 
of cardiac dyspnoea, 98 
of cerebellar tumour, 337 
of cerebral apoplexy, 328 

congestion, 319 

embolism, 551 

paralysis, 377 

sinuses, thrombosis of, 353 

tumour, 337 
of cerebro-spinal fever, 72 
of chicken-pox, 49 
of chorea, 304 

of club-foot from infantile spinal pa- 
ralysis, 377 
of colic, 674 
of congenital syphilis, 211 

malformation of heart, 540 
of constipation, 620 
of contraction, tonic, of extremities, 

275 
of convulsions, 281 
of cretinism, 396 
of croup, false, 413 

membranous, 101 
of cyanosis, 540 

of dentition, derangements of, 561 
of diarrhoea, choleraic, 644 

inflammatory, 634 
of dilated bronchi, 514 
of diphtheria, 100 
of diphtheritic paralysis, 101 
of dysentery, 650, 674 
of dyspnoea, cardiac, 98 

paroxysmal, 521 
of eczema, 792 
of emphysema, 494 
of empyema, 454 
of encephalitis, 353 
of endocarditis, acute, 162 

ulcerative, 162 
of enteric fever, 63 
of epidemic roseola, 31 
of epilepsy, 290 
of erysipelas, 112 
of erythema simplex, 783 

nodosum, 784 
of facial paralysis, 369 
of faecal masses in bowels, 186, 664 
of foreign body in air-tubes, 531 
of gangrene of lung, 499 

spontaneous, 170 
of gangrenous varicella, 49 
of generalised myelitis, 377, 382 
of haemophilia, 245 
of haemorrhage, gastro-intestinal, 657 



Diagnosis of haemorrhage into spinal cord, 
377 
of heart, congenital disease of, 540 

valvular disease of, 550 
of hydatid of liver, 740 
of hydrocephalus, acute, 362 

chronic, 345 
of hydronephrosis, 703, 774 
of hydrothorax, 455 
of hysterical aphonia, 409 
of icterus neonatorum, 719 
of idiocy, 395 

of infantile spinal paralysis, 377 
of inherited syphilis, 211 
of intussusception, 673 
of jaundice, r < 19 
of kidney, calculus of, 767 

tumour of, 773 
of laryngismus str.dulus, 271 
of laryngitis, chronic, 409 

simple, 408 

stridulous, 413 

tubercular, 417 
of larynx, abscess of, 420 

anaemia of, 409 

oedema of, 414 

scald of, 409 

warty growths of, 417 
of leucocythemia, 218 
of liver, amyloid, 732 

cirrhosis of, 729 

congestion of, 729 

fatty, 736 

hydatid of, 740 
of lung, collapse of, 469 

fibroid, 478 

gangrene of, 499 
of lymph adenoma, 227 
of measles, 26 
of megrim, 296 
of meningitis, purulent, 353 

tubercular, 362 
of molluscum contagiosum, 797 
of mumps, 67 
of myelitis, acute generalised, 377, 

382 
of nettlerash, 786 
of oedema of larynx, 414, 594 
of oedema of new-born infants, 808 
of otitis, 352 
of paralysis, cerebral, 377 

diphtheritic, 101 

facial, 369 

infantile spinal, 377 

pseudo-hypertrophic, 387 

spasmodic spinal, 382 
of pemphigus, 780 
of pericarditis, 161 

suppurative, 162 
of peritonitis, acute, 674, 689 

tubercular, 697 
of perityphlitis, 683 
of pharyngitis, follicular, 579 

herpetic, 580 

tubercular, 582 
of phthisis, fibroid, 478 



INDEX. 



819 



Diagnosis of phthisis, pulmonary, acute, 
507 

pulmonary, chronic, 513 
of pleurisy, 453 
of pneumonia, catarrhal, 439 

cerebral, 430 

croupous, 430 
of portio dura, paralysis of, 369 
of purpura hemorrhagica, 251 

simplex, 251 
of quinsy, 588 

of retro-pharyngeal abscess, 594 
of rheumatism, acute, 161 

of abdominal muscles, 161 
of rickets, 143 
of ringworm, 801 
of roseola, 787 
of scabies, 799 
of scarlet fever, 41 
of sclerema, 808 
of scrofula, 185 
of scurvy, 257 
of small-pox, 61 

of spasmodic spinal paralysis, 382 
of spinal caries, 185 
of splenic tumour, 240 
of spontaneous gangrene, 170 
of stomatitis, aphthous, 564 

gangrenous, 569 

ulcerative, 566 
of syphilis, inherited, 211, 602 
of teething, derangements of, 561 
of tetanus, 312 
of tetany, 275 
of thrush, 574 
of tinea circinata, 801 

favosa, 805 

tonsurans, 801 
of tuberculosis, 198 

in infants, 199 

in infants from infantile atrophy, 
601 
of tumour of brain, 337 

of kidney, 773 
of typhlitis, 682 
of ulceration of bowels, 664 
of urticaria, 786 
of varicella, 49 
of variola, 61 
of varioloid, 49 
of variolous roseola, 61 
of vulvitis, aphthous, 776 
of whooping-cough, 122 
of worms, intestinal, 711 
Diaphragm, paralysis of, 100 

diagnosis of, 102 
Diaphragm, spasm of, 270 
Diarrhoea, choleraic, 642 
causation of, 642 
collapse in, 643 
diagnosis of, 644 
duration of, 644 
hypodermic injection of morphia in, 

646 
koumiss in treatment of, 644 
morbid anatomy of, 642 



Diarrhoea, choleraic, prognosis in, 644 

rapid wasting in, 643 

salicylate of lime in treatment of, 645 

stools in, 643 

symptoms of, 642 

temperature in, 643 

treatment of, 644 

vomiting in, 643 
Diarrhoea, chronic, 633 

diagnosis of, 634 

diet in, 640 

nitrate of silver in treatment of, 641 

prognosis in, 635 

raw meat in treatment of, 640 

symptoms of, 633 

treatment of, 640 
Diarrhoea from fecal accumulation in rec- 
tum, 619 

diagnosis of, 621 

in cases of ulceration of bowels, 662 
Diarrhoea, inflammatory, 629 

astringents in treatment of, 638 

causation of, 629 

character of stools in, 630 

cold bathing in treatment of, 637 

diagnosis of, 634 

diet in, 636 

ipecacuanha in treatment of, 638 

morbid anatomy of, 630 

parenchymatous nephritis in, 632 

prognosis in, 635 

rapid wasting in, 631 

spurious hydrocephalus in, 632 

symptoms of, 630 

temperature in, 631 

treatment of, 636 
Diarrhoea, iienteric, 626 

treatment of, 628 

nocturnal, from lumbricus, 710 
Diarrhoea, simple, 624 

causation of, 624 

morbid anatomy of, 626 

relation of, to teething, 556 

symptoms of, 625 

treatment of, 626 
Diathesis, the scrofulous, 175 

two types of, 176 
Diathetic diseases, the, 173 
Diet in anemia, 234 

in ascites, 704 

in atelectasis, congenital, 464 
post-natal. 472 

in atrophy, infantile, 603 

in Bright's disease, acute, 46 
chronic, 761 

in bronchitis, 487 

in calculus of kidney, 768 

in cancrum oris, 569 

in cerebral haemorrhage, 329 

in chorea, 305 

in congenital syphilis, 214 

in constipation, 623 

in dentition, 562 

in diarrhoea, choleraic, 644 
inflammatory, acute, 536 
inflammatory, chronic, 640 



820 



INDEX. 



Diet in diphtheria, 103 

in dysentery, acute, 651 

chronic, 653 
in eczema, 793 
in emphysema, 495 
in empyema, 460 
in enteric fever, 85 
in epilepsy, 292 
in erysipelas, 113 
in erythema nodosum, 785 
in extremities, tonic contraction of, 

276 
in gangrene of lung, 501 

spontaneous, 171 
in gastric catarrh, 607, 615 
in haemophilia, 246 
in heart, valvular disease of, 553 
in icterus neonatorum, 721 
in idiocy, 397 
in intussusception, 677 
in kidney, calculus of, 768 
in laryngismus stridulus, 273 
in laryngitis, 411 
in larynx, suppuration about, 421 
in liver, congestion of, 724 

cirrhosis of, 730 
in lung, collapse of, 464, 472 

fibroid, 480 

gangrene of, 501 
in measles, 29 
in megrim, 298 
in melasna neonatorum, 659 
in mumps, 67 
in nighb terrors, 562 
in peritonitis, acute, 691 

tubercular, 699 
in perityphlitis, 684 
in pharyngitis, herpetic, 581 

tubercular, 583 
in phthisis, fibroid, 480 

pulmonary, acute, 517 

pulmonary, chronic, 517 
in pleurisy, 457 
in pneumonia, catarrhal, 442 

croupous, 432 
in purpura, 252 
in quinsy, 589 
in rheumatism, acute, 164 
in rickets, 144 
in scarlet fever, 44 
in sclerema, 809 
in scrofula. 187 
in scurvy, 258 
in small-pox, 62 
in splenic tumour, 240 
in spontaneous gangrene, 171 
in stomatitis, gangrenous, 569 

ulcerative, 566 
in syphilis, infantile, 214 
in teething, 562 
in tetanus, 313 
in tetany, 276 
in thrush, 575 
in tuberculosis, 201 
in typhlitis, 684 
in ulceration of bowels, 666 



Diet in urticaria, 786 

in whooping-cough, 124 
Digitalis as a diuretic for children, 47 

value of, in heart disease, 553 
Diphtheria, 89 

albuminuria in, 95 

and croup, identity of, 88 

antiseptic sprays in, 104 

cardiac thrombosis in, 98 

causation of, 90 

complicating scarlatina, 38 

complications of, 97 

diagnosis of, 100 

diet in, 103 

failure of heart in, 99 

false membrane of, 92 

forced feeding in, 107 

infection, duration of, in, 90 

laryngeal (see Membranous Croup), 95 

local remedies in, 104 

malignant, 97 

mild form of, 93 

morbid anatomy of, 91 

nasal, 98 

paralytic lesions in, 99 

prognosis in, 102 

secondary, 97 

severe form of, 94 

sudden death in, 99 

symptoms of, 93 

temperature in, 95 

treatment of, 103 

urine in, 95 

varieties of, 93 
Douche, cold, in treatment of chorea, 305 

of laryngismus stridulus, 272 

of rickets, 146 

of scrofula, 188 
Douche, cold, precautions in giving, 17 

therapeutic value of, 16 
Dover's powder in treatment of dysentery, 
652 

of inflammatory diarrhoea, 638 
Drinking, mode of, significance of, 13 
Dropsy after scarlet fever, 39 

in acute Bright's disease, 39 

in chronic Bright's disease, 754 

in heart disease, 547 
Drowsiness after c< nvulsions, 262, 280 

as a sign of cerebral disease, 262 

from disturbed sleep, 320 

in acquired hydrocephalus, 344 

in ague, 149 

in cerebral congestion, 318 

in congenital atelectasis, 462 
malformation of heart, 540 

in croupous pneumonia, 425 

in encephalitis, 351 

in hypertrophic cirrhosis of liver, 729 

in lymphadenoma, 224 

in malignant scarlet fever, 37 

in purulent meningitis, 349 

in spasmodic stage of whooping-cough, 
116 

in spontaneous gangrene, 168 

in tubercular meningitis, 359 



INDEX. 



821 



Drowsiness in uraemia, 755 
significance of, 262 

Ductus arteriosus, time of closure of, 536 

Dyspnoea, cardiac, 98 
causes of, 519 
definition of, 519 
expiratory, 522 
from ascites, 701 

from clotting of blood in heart, 98 
from congenital malformation of heart, 

538, 541 
from embarrassed pulmonary circula- 
tion, 427 
from enlarged bronchial glands, 182, 

522 
from foreign body in air- tubes, 527 
from interstitial oedema of lung, 39 
from membranous laryngitis, 96 
from oedema of glottis, 407 
from paralysis of diaphragm, 100 
from pressure on larynx, 420 
on lung, 449, 519 
# from retro-pharyngeal abscess, 592 
from sarcoma of kidney, 771 
from scald of glottis, 407 
from softened ribs in rickets, 519 
from stridulus laryngitis, 412 
from suppuration about larynx, 419 
in acute pulmonary phthisis, 506 
in bronchial astbma, 521 
in capillary bronchitis, 484 
in catarrhal pneumonia, 437 
in croupous pneumonia, 427 
in diphtheria, 96 
in peritonitis, 687 
in pleurisy, 449 
in pulmonary gangrene, 498 
in valvular disease of heart, 547 
inspiratory, 522 

Dyspnoea, paroxysmal, causes of, 519 
definition of, 520 
diagnosis of, 521 

Ear, haemorrhage from, in hsemorrhagic 
purpura, 249 

in melsena neonatorum, 656 

in pertussis, 118 
Ear, inflammation of middle (see Otitis), 
345 

malformation of, in the idiot, 396 

position of, in the idiot, 396 
Earache, convulsions from, 348 

peculiar cry of, 9 

signs of, in the infant, 348 
Eclampsia (see Convulsions), 277 
Ecthyma, 780 
Eczema, 789 

capitis, 790 

causation of, 789 

diagnosis of, 792 

diet in, 793 

infantile, 791 

rubrum, 790 

simplex, 790 

symptoms of, 790 

tarsi, 791 



Eczema, treatment of, 792 

varieties of, 790 
Emboli of minute arteries as a cause of 

chorea, 300 
Embolism, cerebral, case of, 548 

of umbilical veins a cause of haemor- 
rhage from navel, 654 
Embolisms, various, in cases of ulcerative 

endocarditis, 158, 547 
Emetics in treatment of bronchitis, 487 

of collapse of lung, 464, 471 

of fibroid induration of lung, 480 

of si ridulous laryngitis, 414 
Emphysema, pulmonary, 491 

causation of, 491 

diagnosis of, 494 

diet in, 495 

morbid anatomy of, 492 

prognosis in, 495 

symptoms of, 493 

treatment of, 495 
Empyema, 477 

clubbing of fingers in, 455 

diagnosis of, 454 

diet in, 460 

symptoms of, 447 

temperature in, 447 

treatment of, 458 
Encephalitis, 347 

convulsions in, 351 

diagnosis of, 162 

duration of, 351 

morbid anatomy of, 347 

paralysis in, 351 

pulse in, 351 

stupor in, 351 

symptoms of, 351 

temperature in, 351 

treatment of, 354 
Endocarditis, rheumatic, 155 

diagnosis of, 162 

morbid anatomy of, 154 

prognosis in, 163 

rest, importance of, in, 165 

treatment of, 165 
Endocarditis, ulcerative, 154 

diagnosis of, 162, 552 

morbid anatomy of, 154 

symptoms of, 154, 547 
Enemata, astringent, in diarrhoea, 639 

in dysentery, 653 

in ulceration of bowels, 667 
Enemata. sedative, in prolapsus ani, 639 

value of, in treatment of constipation. 
622 
Enteric fever, 74 

causation of, 74 

cervical neuralgia in, 79 

character of stools in, 77 

complications of, 81 

constipation in, 77 

deafness in, 72 

defective action of kidneys in, 82 

diagnosis of, 83 

from acute gastric catarrh. 83 

from acute tubercular peritonitis, 698 



822 



INDEX. 



Enteric fever, diagnosis of, from acute 
tuberculosis, 83 

from inflammatory diarrhoea, 83 

from leucocythemia, 218 

from tubercular meningitis, 83 

from typhus fever, 84 

from ulceration of the bowels, 84 

digestive organs in, 76 

duration of, 80 

eruption in, 77 

headache in, 76 

incubation period of, 76 

melaena in, 78 

mode of death in, 81 

morbid anatomy of, 75 

perforation of bowel in, 81] 

prognosis in, 84 

pulse in, 79 

retention of urine in, 78 

secondary pyrexia in, 82 

sequelae of, 82 

swelling of abdomen in, 78 

symptoms of, 76 

temperature in, 79 

treatment of, 85 

urine in, 78 
Entero-colitis (see Diarrhoea, Inflamma- 
tory), 629 
Enuresis (see Urine, Nocturnal Inconti- 
nence of), 748 
Epidemic roseola, 30 

diagnosis of, 31 

symptoms of, 30 

treatment of, 30 
Epigastrium, pain in, as a sign of spinal 

caries, 178 
Epilepsy, 286 

association of, with chorea, 290 

bromides f i r, 292 

causation of, 286 

diagnosis of, 290 

diet in, 292 

influence of, on mental development, 
289 

pathology of, 287 

prognosis in, 291 

symptoms of, 287 

treatment of,- 291 
Epileptic vertigo, 288 
Epiphyses, ossification of, in rickets, 132 

separation of, in infantile syphilis, 210 
in scurvy, 256 
Eoistaxis from enlarged bronchial glands, 
181 

in acute tuberculosis, 194 

in anaemia, 238 

in atrophic cirrhosis of liver, 728 

in enteric fever, 79 

in fibroid induration of lung, 477 

in haemophilia, 243 

in hemorrhagic purpura, 249 

in heart disease, 547 

in idiopathic anaemia, 233 

in leucocythemia, 218 

in lymphadenoma, 226 

in measles, 25 



Epistaxis in splenic enlargement, 238 

in whooping-cough, 116 

simulating haemoptysis, 117, 477 
haematemesis, 117, 654 
inelaena, 117 

treatment of, 252 

in haemophilia, 246 
Ergot in treatment of epilepsy, 293 

of incontinence of urine, 750 

of haemoptysis, 518 

of megrim, 297 
Eruption (see Rash) 
Erysipelas, 109 

abscesses in, 110 

causation of, 109 

complications of, 110 

desquamation of skin in, 112 

diagnosis of, 112 

diet in, 113 

duration of, 112 

gangrenous sloughs in, 110 

idiopathic, 112 

laryngitis in, 110 m 

local applications in, 113 

morbid anatomy of, 110 

prognosis in, 112 

puerperal, 110 

symptoms of, 111 

temperature in, 110 

treatment of, 113 

white lead paint as an application for, 
113 
Erythema fugax, 782 
Erythema intertrigo, 782 

symptoms of, 782 

treatment of, 783 
Erythema nodosum, 783 

diagnosis of, 784 

symptoms of, 783 

temperature in, 784 

treatment of, 784 
Erythema papulatum, 782 
Erythema simplex, 782 

diagnosis of, 783 

treatment of, 783 

varieties of, 782 
Examination, clinical, of infants, 6 

of abdomen, 12 

of chest, 399 

of fontanelle, 9 

of liver, 723 

of mouth, 13 

of spleen, 237 

of stools in diarrhoea, 14 

of throat, 13 

of tongue, 13 
Exanthemata in the subjects of haemo- 
philia, 245 

of scrofula, 24, 42, 174 
Exercise, want of, a cause of constipation, 

619 
Expectorants in bronchitis, 487 
Expression, distressed, a sign of disease, 

7, 265, 663 
External applications, 16 
Extremities, tonic contraction of, 274 



INDEX. 



823 



Extremities, tonic contraction of, calabar 
bean in treatment of, 276 
causation of, 274 
diagnosis of, 275 
prognosis in, 276 
symptoms of, 274 
treatment of, 276 
Eye, position of, in the idiot, 396 
Eyeball, destruction of, in facial paralysis, 
369 
in small-pox, 59 
Eyelids, bleeding from, in hasniorrhagic 
purpura, 249 
half closed during sleep a sign of 
prostration, 8 
Eyes, bloodshot, in whooping-cough, 118 
prominent in chronic hydrocephalus, 
342 

Face, expression of, in infants, 6 
Facial nerve in the Fallopian canal, 367 

paralysis (see Portio Dura, Paralysis 
of), 367 
Facies, distressed, a sign of disease, 7, 663 
Pascal concretions, 678 

masses in bowel, diagnosis of, 186, 664 
Fasces, accumulation of, in bowels, 620 
Fasces, impaction of, 619 

diagnosis of, 674 

seat of, 619 

symptoms of. 619 

treatment of, 623 
Faradisation of muscle in infantile spinal 
paralysis, 378 

of spleen in leucocythemia, 219 
Fatty degeneration of liver in entero-co- 
litis, 735 

of organs in anasmia, 232 

of organs in purpura, 248 
Fauces (see Throat) 

Features, alteration of, in follicular pha- 
ryngitis, 579 

in hypertrophy of tonsils, 587 
Feeding, forced, of children, 15 
Feet, coldness of, in anasmia, 232 

in congenital malformation of heart, 
538 
Fever, general considerations on, 10 

irritative, 10 
Fibroid induration of lung, 473 

amyloid degeneration of organs in, 477 

contraction of side in, 477 

diagnosis of, 478 

diagnosis from pleurisy with retrac- 
tion, 478 
from pulmonary phthisis, 478 

dilatation of bronchi in, 474 

morbid anatomy of. 474 

offensive sputum in, 477 

paroxysmal cough in, 476 

pathology of, 473 

physical signs of, 476 

prognosis in, 479 

symptoms of, 475 

temperature in, 477 

treatment of, 478 



Fibroid nodules in acute rheumatism, 160 

Fibroid phthisis. 475, 477 

Fingers, clubbing of, in amyloid liver, 732 

in chronic bronchitis, 485 

in cirrhosis of lung, 477 

in congenital heart disease, 526 

in empyema, 455 
Flatulence, 619 

treatment of, 622 
Flea-bites, petechias from, in anasmic 

children, 233 
Fluid in chronic hydrocephalus, 341 

in hydatid cysts, 737 

in hydronephrosis, 772 

in pleurisy, 444 
Flush, cerebral, 265, 359 
Flushing of face in acute tuberculosis, 195 

in croupous pneumonia, 425 

in enteric fever, 77 

in leucocythemia, 217 

in lymphadenoma, 224 

in tubercular meningitis, 359 
Foetus, circulation in the, at term, 535 
Fontanelle in chronic hydrocephalus, 341 

in idiocy, 396 

in rickets, 137 

in syphilis, inherited, 210 

in tubercular meningitis, 360 

in wasted infants, 9 
Food (see Diet) 

farinaceous, as a diet for infants, 604 
Foramen ovale, closure of the, 536 

patency of the, 539 
Foreign body in air-tubes, 526 

diagnosis of, 523, 531 

dyspnoea from, 522, 523, 527 

morbid anatomy of, 526 

pain in chest in, 527 

physical signs of, 528 

prognosis in, 533 

seat of, 530 

spasmodic cough from, 527 

spontaneous expulsion of, 529 

symptoms of, 527 

treatment of, 533 
Fremitus, vocal, often absent in early life, 

401 
Friction, pericardial, 156 

pleural, 449 
Fright as a cause of chorea, 299 

of epilepsy, 286 

of incontinence of urine, 748 
Function, disorder of, in childhood, 3 

Gait, peculiarities of, in cerebellar tu- 
mour, 337 

in pseudo-hypertrophic paralysis, 385 

in spasmodic spinal paralysis, 382 
Galvanism in facial paralysis, 370 

in hysterical affections, 266 

in infantile spinal paralysis, 378 

in leucocythemia, 219 

in pseudo-hypertrophic paralysis, 385 
Gangrene following scarlet fever, 40 

of cheek (see Stomatitis, Gangrenous), 
567 



824 



INDEX. 



Gangrene, pulmonary, 496 

causation of, 496 

diagnosis of, 499 

diet in, 501 

duration of, 499 

dyspnoea in, 498 

haemoptysis in, 498 

morbid anatomy of, 497 

physical signs of, 499 

prognosis in, 500 

pulse in, 498 

respirations in, 498 

symptoms of, 497 

temperature in, 498 

treatment of, 500 
Gangrene, spontaneous, 166 

causation of, 166 

cause of death in, 170 

diagnosis of, 170 

diet in, 171 

hematuria in, 168 

iodoform in treatment of, 171 

local applications for, 171 

morbid anatomy of, 167 

of extremities, 169 

of vulva, 170 

pathology of, 166 

prognosis in, 171 

symmetrical, 167 

symptoms of, 167 

temperature in. 170 

treatment of, 171 ■ 

varieties of, 167 
Gangrenous sloughs in erysipelas, 110 

in varicella, 49 
Gastric catarrh in infants, 601 

diet in, 607 

incapacity for digesting milk in, 606 

often a cause of death, 598 

symptoms of, 601 

treatment of, 606 

vomiting from, 601 
Gastric catarrh in older children, 609 

causation of, 609 

diagnosis of, 612 

diet in, 615 

febrile form of, 610 

jaundice in, 610, 614 

morbid anatomy of, 610 

nervous symptoms in, 611 

non-febrile form of, 611 

symptoms of, 610 

tongue in, 611 

treatment of, 615 
Gelatine in the hand-feeding of infants, 604 
Gelatiniform softening of bone in inherit- 
ed syphilis, 207 
Giant cells in tubercle, 192 
Glandular enlargement in lymphadenoma, 

220 
Glands, bronchial (see Bronchial Glands), 
178 

mesenteric (see Mesenteric Glands), 
183 

post-cervical, enlarged in epidemic 
roseola, 31 



Glands, post-cervical, enlarged in inherit- 
ed syphilis. 210 
Gliomatous tumour of brain, case of, 333 
Glottis, catarrh of (see Laryngitis), 406 
impaction of foreign body in, 529 
oedema of, 409 

diagnosis of, 413 
treatment of, 410 
scald of, 407 

spasm of (see Laryngismus Stridulus), 
267 
Goitre in endemic cretinism, 396 
Granulation, the gray, 190, 192 
Growth, rapid, pyrexia from, 11 
retarded in cretinism, 393 
in idiocy, 392 

in infantile spinal paralysis, 373 
in inherited syphilis, 211 
in rickets, 140 
Guiaiacum as a remedy for acute eczema, 

793 
Gums, bleeding from, in anaemia, 233 
in cirrhosis of liver, 728 
in haemophilia, 243 
in melsena neonatorum, 656 
in purpura haemorrhagica, 249 
in scurvy, 256 

in ulcerative stomatitis, 565 
Gums in cyanosis, 539 

in gangrenous stomatitis, 567 
in purpura, 250 
in scurvy, 256 

in ulcerative stomatitis, 565 
lancing of, in convulsions of teething, 
562 

ILEMATEMEsrs, spurious, 654 

causes of, 654 

diagnosis of, 657 
Haematemesis, true, causes of, 654 

diagnosis of, 657 

in haemophilia, 243 

in hemorrhagic purpura, 249 

in infants, 654 

in intussusception, 672 

prognosis in, 658 

treatment of, 659 
Hsematomata on auriculo ventricular 

valves, 546 
Haematuria, causes of, 746 

from calculus of kidney, 765 

from embolism of kidney, 158 

from irritation of passages by the bil- 
harzia hsematobia. 747 

from sarcoma of kidney, 765 

in ague, 149 

in asthenic measles, 24 

in Bright' s disease, acute, 39 
chronic, 765 

in cerebro- spinal fever, 71 

in diphtheria, 95 

in hemorrhagic purpura, 249 

in lymphadenoma. 224 

in malignant small-pox, 60 

in scarlet fever, 39 

in scurvy, 257 



INDEX. 



825 



Hematuria in spontaneous gangrene, 168 

in ulcerative endocarditis, 158 

rare in haemophilia, 243 
Haemoglobin reduced in anaemia, 229 
Haemophilia, 242 

aperients in, 246 

causation of, 242 

diagnosis of, 245 

diet in, 246 

haemorrhages in, 243 

joint affection in, 244 

morbid anatomy of, 242 

pains in limbs in, 244 

prognosis in, 245 

symptoms of, 243 

three grades of, 243 

treatment of, 246 
Haemoptysis in congenital heart disease, 
538 

in disease of mitral valve, 547 

in pulmonary gangrene, 498 
phthisis, 510 

in whooping-cough, 116 
Haemorrhage, cerebral (see Cerebral Haem- 
orrhage), 322 

conjunctival, in whooping-cough, 118 

from bowels (see Melaena) 

from gums in anaemia, 233 
in cirrhosis of liver, 728 
in haemophilia, 243 
in purpura haemorrhagica, 249 
in scurvy, 256 
in ulcerative stomatitis, 565 

from tonsil in quinsy, 586 
Haemorrhage, gastro-intestinal, 654 

causation of, 654 

diagnosis of, 657 

prognosis in, 658 

symptoms of, 656 

treatment of, 659 
Haemorrhage into spinal cord, diagnosis 
of, 377 

intra-cranial, in purpura, 251 
in whooping-cough, 115 
Haemorrhage, meningeal, causation of, 322 

convulsions in, 324 

diagnosis of, 328 

morbid anatomy of, 323 

prognosis in, 329 

symptoms of, 324 

treatment of, 329 
Haemorrhage, sub-periosteal, in scuivy, 

254 
Haemorrhages, various, in asthenic mea- 
sles, 24 

in haemophilia, 243 

in lsucocythemia, 218 

in purpura, 249 
Haemorrhoids in atrophic cirrhosis of liver, 

717 
Hair in chronic hydrocephalus, 342 

in cretinism, 393 

in rickets, 138 
Hairs in tinea favosa, 804 

in tinea tonsurans. 800 
Hallucinations in cerebro-spinal fever, 70 



Hand-feeding of infants (see Artificial 

Feeding), 603 
Head, retraction of, causes of, 264 

in abscess of larynx, 419 

in cerebro-spinal fever, 69 

in chronic hydrocephalus, 343 

in purulent meningitis, 349 

in retro-pharyngeal abscess, 592 

in tubercular meningiti.:, 360 
Headache after fit of whooping-cough, 116 

hypertrophic, 297 

in anaemia, 233 

in cerebral tumour, 332 

in chronic Bright's disease, 755 
hydrocephalus, 343 

in croupous pneumonia, 425 

in diphtheria, severe, 94 

in enteric fever, 79, 83 

in gastric catarrh, 611 

in megrim, 295 

in purulent meningitis, 349 

in rickets, 137 

in tubercular meningitis, 358 

in uraemia, 39 

occipital, in spinal caries, 178 
in cerebellar tumour, 337 

sign of, in the infant, 8 
Heart, arrest of development of, 536 

degeneration of, death from, 99 
in diphtheria, 92 

disease, causes of, 544 
Heart disease, congenital, 535 

cerebral symptoms in, 540 

clubbing of fingers in, 538 

commonest form of, 536 

common in idiots, 396 

convulsions in, 538 

cyanosis in, 538 

diagnosis of, 540 

disease of petrous bone in, 540 

dropsy in, 538 

drowsiness in, 540 

duration of life in, 540 

dyspnoea in, 538 

modes of death in, 540 

morbid anatomy of, 537 

physical signs in, 539 

prognosis in, 542 

resulting from atelectasis, 463 

symptoms of, 538 

syncope in, 539 

treatment of, 542 

valvular defects in, 537 

varieties of, 536 
Heart disease in acute rheumatism, 155 

in chorea, 303 

normal development of, 535 
Heart, chronic valvular disease of, 544 

ante-mortem clots in, 550 

causation of, 544 

diagnosis of, 550 

diet in, 553 

dyspnoea in, 547 

embolism in, 547 

haemorrhages in, 547 

morbid anatomy of, 545 



826 



INDEX. 



Heart, chronic valvular disease of, palpita- 
tion in, 547 

prognosis in, 552 

symptoms of, 547 

terminations of, 550 

treatment of, 552 

varieties of, 549 
Heart's apex, displacement of, 402 

normal site of, 401 
Hemi-chorea, 302 

Hemiplegia from embolism of brain, 548 
Hernia during spasm of whooping-cough, 
116 

umbilical, from straining at stool, 619 
Herpes, 779 

of pharynx (see Pharyngitis, Her- 
petic), 580 
Hip-joint disease simulated by peri-typhli- 
tis, 680 

diagnosis of, 683 
Hoarseness from anaemia of larynx, 409 

from chronic laryngitis, 408 

from enlarged bronchial glands, 182 

from foreign body in air-tubes, 528, 
530 

from inherited syphilis, 210 

from membranous croup, 95 

from oedema of glottis, 408 

from scald of glottis, 407 

from stridulous laryngitis, 412 

from suppuration about larynx, 420 

from tubercular laryngitis, 416 

from warty growths on larynx, 417 
Hodgkin's disease (see Lymphadenoma) 
Hum, venous, behind sternum, 183 
Hunger, sign of, in the infant, 8 
Hydatid cyst, suppuration of, 739 

treatment of, 743 
Hydatid of liver (see Liver, Hydatid of), 

737 
Hydrocephalus, acute (see Tubercular 

Meningitis), 355 
Hydrocephalus, chronic, 340 

acquired, 340, 344 

arrest of disease in, 344 

causation of, 340 

complicating rickets, 142 

congenital. 340, 342 

diagnosis of, 345 

duration of life in, 344 

fluid in, 342 

fontnnelle in, 341 

headache in, 343 

intelligence in, 343 

late walking in, 343 

mode of death in, 344 

morbid anatomy of, 341 

nervous symptoms in, 343 

nystagmus in, 343 

oedema of brain in, 342 

ophthalmoscopic examination in, 343 

prognosis in, 345 

retraction of head in, 343 

shape of head in, 341 

spontaneous evacuation of fluid in, 344 

sutures in, 341 



Hydrocephalus, chronic, symptoms of, 342 
the senses in, 343 
treatment of, 345 
Hydrocephalus, spurious, 632 
diagnosis of, 635 
treatment of, 639 
Hydronephrosis, 772 
acquired, 766, 772 
causation of, 772 
diagnosis of, 774 

from ascites, 703 
symptoms of, 772 
treatment of, 774 
usually congenital, 772 
Hyperinosis in acute rheumatism, 162 
Hyper-pyrexia, cerebral symptoms from, 
159 
in rheumatism, 159 

treatment of, 163 
in scarlet lever, 45 
reduction of temperature in, 15 
Hypertrophy of muscle in pseudo-hyper- 
trophic paralysis, 384 
of right ventricle in congenital heart 

disease, 537 
of spleen (see Spleen, Simple Hyper- 
trophy of), 238 

Ice-bag to head and spine in cerebro- 
spinal fever, 73 

to head in tubercular meningitis, 366 
Icterus (see Jaundice), 714 

malignus, 718 
Icterus neonatorum, 714 

causation of, 715 

diagnosis of, 719 

prognosis in, 720 

treatment of, 720 
Idiocy, 389 

acquired, 390 

association of, with malformations, 392 

Aztec type of, 390 

causes of, 389 

classification of, 391 

common in first-born children, 389 

congenital, 392 

defective speech in, 894 

diagnosis of, 395 

earliest signs of, 396 

insensibility to pain in, 394 

mental condition in, 394 

morbid anatomy of, 890 

obtuseness of senses in, 394 

prognosis in, 896 

symptoms of, 391 

treatment of, 397 

varieties of, 391 
Idiopathic anaemia, 231 

symptoms of, 233 
Idiopathic contractures (see Extremities, 

Tonic Contraction of), 274 
Ilium, catarrh of, stools in, 630 
Impetigo contagiosa, 791 
Incubation period in chicken-pox, 48 

in diphtheria, 93 

in epidemic roseola, 30 



INDEX. 



827 



Incubation period in measles, 21 

in mumps, 65 

in scarlet fever, 33 

in small-pox, 56 

in whooping-cough, 115 
Indican in urine, test for, 635 
Indigestion a cause of infantile atrophy, 
598 

from constipated bowels, 620 

in infants, 600 

treatment of, 603 

in older children, 611, 612 

of breast-milk, 599 

of cow's milk, 597 

treatment of, 606, 607 

of starch in infancy, 598 
Infancy, convulsions in, clinical import- 
ance of, 3 

definition of, 5 

modes of death in, 4 

nervous excitability in, 2 

physiological peculiarities of, 2 

pulse in, 9 

respiration in, 10, 12 

sudden death in, 5 

temperature in, 10 
Infantile atrophy, 596 

causation of, 596 

constipation in, 601 

diagnosis of, 602 

diarrhoea in, 602 

diet in. 605 

eruptions in, 601 

inability to digest cow's milk in, 605 

indigestion in, 600 

prognosis in, 603 

state of bowels in, 601 

symptoms of, 600 

temperature in, 602 

treatment of, 603 

vomiting in, 601 
Infantile paralysis (see Paralysis, Acute 

Infantile Spinal), 371 
Infants' foods, 602 

general management of. 604 
Infection, duration of, in diphtheria, 90 

in measles, 22 

in mumps, 67 

in scarlet fever, 32 

in small-pox, 55 

in whooping-cough, 114 
Inflation of bowel in intussusception, 676 

of lung in atelectasis, 461 
Inhalations, antiseptic, in chronic bron- 
chitis. 4S9 

in diphtheria, 104 

in fibroid induration of lung, 480 

in membranous croup, 104 

in whooping-cough. 126 
Injections, aural, 189, 354 

intestinal, 638, 639, 653 

nasal, 105 

of air in intussusception, 676 

of ipecacuanha in colitis, 638 

of nitrate of silver in ulceration of the 
bowels, 667 



Inspiration, retraction of chest in, 400 
Intelligence in chorea, 303 

in chronic hydrocephalus, 343 

in rickets, 141 

in tumour of brain, 333 
Intermittent fever (see Ague), 147 
Internal convulsions (see Laryngismus 

Stridulus), 267 
Intertrigo (see Erythema Intertrigo), 782 
Intestinal worms (see Worms, Intestinal), 

705 
Intestines, catarrh of, 624 

ulceration of (see Bowels, Ulceration 
of), 660 
Intussusception, 668 

bloody stools in, 670 

causation of, 668 

colic in, 670 

diagnosis of, 673 

diet in, 677 

duration of. 673 

morbid anatomy of, 668 

prognosis in, 675 

seat of, 669 

symptoms of. 670 

temperature in, 670 

tenesmus in. 670 

treatment of, 676 

tumour of abdomen in, 672 

vomiting in, 672 
Invagination of bowels (see Intussuscep- 
tion). 668 
Inward fits, 279 

Iodine in treatment of amyloid degen- 
eration, 733 

of scrofula, 189 
Iodoform in treatment of aphthous vul- 
vitis, 777 

of gangrene of vulva, 171 

of gangrenous varicella, 50 
Ipecacuanha in treatment of bronchitis, 487 

of catarrh of colon, 638 

of dysentery, 651 

of inflammatory diarrhoea, 638 

of tenesmus, 638 

of vomiting, 639 
Ipecacuanha, injections of, in colitis, 638 
Irritative fever, 10 
Itch (see Scabies), 798 

Jaborandi in treatment of urasmia, 47 
Jadelot's lines, 7 
Jaundice, 714 

catarrhal. 614 
in amyloid liver, 732 
in childhood, 719 
causes of, 719 
treatment of, 721 
in croupous pneumonia, 430 
in hypertrophic cirrhosis of liver, 723 
in infancy (see Icterus Neonatorum), 
714 
Jaws, growth of. in rickets, 138 

stiffness of, in infantile tetanus, 310 
in retro-pharyngeal abscess, 594 
Jejunum, catarrh of, stools in, 634 



828 



INDEX. 



Joints, enlargement of, in haemophilia, 
244 

in inherited syphilis, 206 . • 

in rickets, 137 

in scurvy, 250 
Joints, looseness of , in infantile spinal par- 
alysis, 377 

in rickets, 138 
Joints, rheumatic inflammation of, 155 
Joints, rigidity of, in cerebral paralysis, 
377 

in cerebro-spinal fever, 69 

in encephalitis, 351 

in purulent meningitis, 349 

in spasmodic spinal paralysis, 381 

in tetanus, 310 

in tetany, 274 

in tubercular meningitis, 360 

significance of, 263 

Kamala in treatment of tape-worm, 713 
Keratitis, scrofulous, 177 

syphilitic, 211 
Kidney, calculus of, 763 

alkalies in treatment of, 768 
causation of, 764 
diagnosis of, 767 
diet in, 768 
hematuria from, 765 
prognosis in, 768 
pyelitis from, 766 
renal colic from, 766 
symptoms of, 764 
treatment of, 768 
urine in, 765 
Kidney, dropsy of (see Hydronephrosis), 772 
fatty, the, 753 

diagnosis of, 760 
treatment of, 760 
granular, the, 753 

symptoms of, 755 
haemorrhage from (see Haematuria), 

746 
sarcoma of, 770 

diagnosis of, 773 
symptoms of, 771 
tuberculosis of, 193 
tumours of, 770 

diagnosis of, 773 
morbid anatomy of, 770 
treatment of, 774 
Kidney, the amyloid, 753 
diagnosis of, 760 
occasional cure of, 760 
symptoms of, 757 
treatment of, 760 

Bright' s disease of (see Bright's Dis- 
ease), 752 
Knees, pain in, in spinal caries, 178 

swelling of, in haemophilia, 242, 244 
Koumiss ia treatment of choleraic diar- 
rhoea, 644 
of inflammatory diarrhoea, 636 

Labial line, significance of, 7 

Lactic acid, formation of, in rickets, 131 



Laryngismus stridulus, 267 

ammonia in treatment of, 272 

an occasional sequel of whooping- 
cough, 121 

asphyxia in, 271 

association of, with rickets, 267 

attacks of, 269 

causation of, 267 

chloral in treatment of, 273 

cold sponging in treatment of, 272 

death from, 270 

diagnosis of, 271 

in syphilitic infants, 210 

incarceration of epiglottis in, 271 

musk in treatment of, 273 

prognosis in, 272 

spasm of diaphragm in, 270 

symptoms of, 269 

temperature in, 270 

treatment of, 272 
Laryngitis, chronic, 406 

causes of, 406 

diagnosis of, 409 

from hysterical aphonia, 409 

treatment of. 411 
Laryngitis in epidemic roseola, 30 

in erysipelas, 110 

in measles, 25 

in small-pox, 59 

membranous (see Croup, Membran- 
ous), 95 

simulated by anaemia of larynx, 409 
Laryngitis, simple, 406 

calomel in treatment of, 410 

causation of, 406 

collapse of lung from, 407 

death from, 408 

diagnosis of, 408 

duration of, 408 

dyspnoea in, 407 

from scald, 407 

morbid anatomy of, 406 

prognosis in, 410 

treatment of, 410 
Laryngitis stridulosa, 411 

albuminuria in, 412 

at onset of catarrhal pneumonia, 439 
of measles, 25 

causes of, 41 1 

complications of, 413 

diagnosis of. 413 

from laryngismus stridulus, 271 
from membranous croup, 413 
from oedema of glottis, 414 
from retro-pharyngeal abscess, 
414 

dyspnoea in, 412 

morbid anatomy of, 411 

paroxysms of, 412 

prognosis in, 414 

symptoms of, 412 

temperature in, 412 

treatment of, 414 
Laryngitis, tubercular, 415 

causation of, 415 

diagnosis of, 417 



INDEX. 



829 



Laryngitis, tubercular, dyspnoea in, 416 

husky voice in, 416 

prognosis in, 418 

symptoms of, 416 

treatment of, 418 
Laryngoscope, difficulty of using, 417 

value of, in diagnosis, 26 
Larynx, anaemia of, 26, 409 

catarrh of (see Laryngitis), 408 

external pressure on, 420 

impaction of foreign body in, 530 
Larynx, oedema of, 409 

diagnosis of, 409, 414 

treatment of, 410 
Larynx, scald of, 407 

spasm of (see Laryngismus Stridulus), 
267 

spasm of, in whooping-cough, 118 
Larynx, suppuration about, 419 

aphonia in, 420 

causes of, 419 

death from, 420 

diagnosis of, 420 

from retro-pharyngeal abscess, 420 

diet in, 421 

difficulty of swallowing in, 420 

dyspnoea from, 419 

hoarse cough id, 420 

orthopnoea in, 420 

prognosis in, 421 

stridulous respiration in, 420 

swelling of throat in, 420 

symptoms of, 419 

treatment of, 421 
Larynx, warty growths of, 417 
Latent otitis, 348 

peritonitis, 688 

scarlatina, 40 
Leeches in treatment of acute peritoni- 
tis, 691 

of typhlitis, 684 
Leucocytes, excess of, in blood, 217 
Leucocythemia, 216 

alteration of blood in, 217 

causation of, 216 

complexion in, 217 

diagnosis of. 218 

enlargement of spleen in, 217 

hasmorrhages in, 218 

morbid anatomy of, 216 

prognosis in, 219 

pulse in, 218 

symptoms of, 217 

temperature in, 218 

treatment of, 219 
Ligaments, looseness of, in infantile spinal 
paralysis, 377 

in rickets, 140 
Lime, hypophosphite of, in treatment of 

pulmonary phthisis, 517 
Liver, amyloid degeneration of, 731 

anaemia in, 732 

causation of, 731 

diagnosis of , 732 

morbid anatomy of, 731 

prognosis in, 733 



Liver, amyloid degeneration of, symptoms 
of, 731 

treatment of, 733 
Liver, cirrhosis of, 726 

atrophic form of, 727 

diagnosis of, 729 

hypertrophic iorm of. 728 

in malformation of bile-ducts, 716 

in tubercular peritonitis, 694 

morbid anatomy of, 726 

prognosis in, 729 

symptoms of, 727 

treatment of, 730 

two forms of, 726 
Liver, congestion of, 722 

causation of, 722 

diagnosis of, 723 

in ague, 148 

treatment of, 151 

in rickets, 134 

morbid anatomy of, 722 

treatment of, 724 
Liver, displacement of, 723 

examination of, 12, 724 
Liver, fatty infiltration of, causation of, 
735 

diagnosis of, 736 

in exhausting disease, 735 

in inflammatory diarrhoea, 630 

in leucocythemia, 217 

in lymphadenoma, 222 

in phthisis, acute, 506 

chronic tubercular, 511 

in rickets, 134 

in tuberculosis, 198 

morbid anatomy of, 735 

symptoms of, 735 

treatment of, 736 
Liver, hydatid of, 737 

causation of, 737 

diagnosis of, 740 

evacuation of fluid in, 741 

morbid anatomy of, 737 

prognosis in, 7^1 

suppuration of cyst in, 739 

symptoms of, 738 

treatment of, 741 
Liver, syphilitic disease of, 205 
inflammation of, 718 

tuberculosis of, 193 
Lividity of face in asthma, bronchial, 521 

in atelectasis, congenital, 462 
post-natal, 467 

in capillary bronchitis, 484 

in cardiac dyspnoea, 98 

in catarrhal pneumonia, 437 

in clotting of blood in heart, 550 

in congenital malformation of heart, 
538 

in croupous pneumonia, 425 

in embarrassed pulmonary circulation. 
427 

in enlarged bronchial glands, 182 

in foreign body in air-tubes, 527 

in interstitial oedema of luug, 39 

in membranous croup, 96 



830 



INDEX. 



Lividity of face in peritonitis, 687 

in pleurisy, 449 

in retro-pharyngeal abscess, 593 

in scald of glottis, 407 

in stridulous laryngitis, 412 

in suppuration about larynx, 419 
Local asphyxia, 167 
Long round worm (see Ascaris Lumbri- 

coides), 705 
Lumbricus (see Ascaris Lumbricoides), 705 
Lungs, catarrh of (see Catarrh, Pulmon- 
ary), 481 

collapse of (see Atelectasis), 461 

diseases of, 399 

emphysema of (see Emphysema, Pul- 
monary), 491 

fibroid induration of (see Fibroid In- 
duration of Lung), 473 

gangrene of (see Gangrene, Pulmon- 
ary), 496 

syphilitic disease of, 205 
Lymph, inoculation of, 53 
Lymphadenoma, 220 

adenoid growths in, 222 

age of children affected by, 220 

anaemia in, 227 

blood in, 222 

causation of, 220 

diagnosis of, 227 

drowsiness in, 224 

duration of, 226 

dyspnoea in, 226 

epistaxis in, 226 

extirpation of growths in, 228 

glandular enlargement in, 221 

kidneys in, 222 

liver in, 222 

morbid anatomy of, 220 

paralysis in, 226 

phosphorus in treatment of, 228 

spleen in, 221 

symptoms of, 222 

temperature in, 224 

treatment of, 227 

ulcerative stomatitis in, 224 

Malarial fever (see Ague), 147 
Malignant diphtheria, 97 

pustule, diagnosis of, 569 

scarlet fever, 36 

small-pox, 60 
Malnutrition (see Infantile Atrophy), 596 
Malt extract in treatment of chronic con- 
stipation, 622 

of chronic diarrhoea, 640 

of rickets, 145 
Malted bread, 666 

Marasmus (see Infantile Atrophy), 596 
Measles a cause of valvular disease of 
heart, 544 

asthenic, 24 

bronchitis in, 25 

catarrhal pneumonia in, 25 

chest symptoms in, 24 

complications of, 25 

convulsions in, 25 



Measles, diagnosis of, 26 

duration of infective period of, 22 

epistaxis in, 25 

eruption of, 22 

incubation stage of, 22 

morbid anatomy of, 22 

otitis in, 25 

prognosis in, 27 

relapse of, 25 

sequelae of, 26 

stridulous laryngitis in, 23 

symptoms of, 22 

treatment of, 23 
Megrim, 294 

causation of, 294 

diagnosis of, 296 

disorders of vision in, 295 

headache in, 295 

neuralgic pains in limbs in, 296 

pathology of, 294 

pulse in, 295 

symptoms of, 295 

treatment of, 297 

value of ergot in treatment of, 297 
Melaena, causes of, 654 

diagnosis of, 657 

in atrophic cirrhosis of liver, 728 

in dysentery, 649 

in enteric fever, 78 

in haemophilia, 243 

in hemorrhagic purpura, 249 

in infants, 654 

in intussusception, 672 

in polypus of rectum, 656 

in ulceration of bowels, 662 

prognosis in, 658 

spurious, 654 

causes of, 654 
diagnosis of, 657 

treatment of, 659 
Melaena neonatorum, 654 

causes of, 654 

diagnosis of, 657 

symptoms of, 656 

treatment of, 659 
Mellin's food in artificial feeding, 604 
Membrane, false, in diphtheria, 92 
Meningeal haemorrhage (see Haemorrhage, 

Meningeal), 324 
Meningitis, basic, in syphilitic children, 
211 

cerebro - spinal (see Cerebro - spinal 
Fever), 68 
Meningitis, purulent, 346 

breathing in, 349 

causation of, 346 

convulsions in, 349 

convulsive form of, 349 

diagnosis of, 353 

duration of, 349 

headache in, 349 

morbid anatomy of, 347 

phrenitic form of, 350 

prognosis in, 354 

stupor in, 349 

symptoms of, 348 



INDEX. 



831 



Meningitis, purulent, temperature in, 349 

treatment of, 354 
Meningitis, tubercular (see Tubercular 

Meningitis), 355 
Mercury as a cause of anaemia, 231 

in treatment of acute dysentery, 652 
of inherited syphilis, 214 
of oedema of glottis from scald, 
410 
Mesenteric glands, enlargement of, 183 

diagnosis of, 184 

prognosis in, 186 

signs of pressure from, 184, 224 

symptoms of, 184 

termination of, 186 

treatment of, 187 
Metastasis of mumps, 66 
Micturition, painful, from uric acid in 
water, 765 

from contracted prepuce, 767 

in vulvitis, 775 
Micrococci in croupous pneumonia, 424 

in diphtheria, 91 

in erysipelas, 110 

in stomatitis, 91 
Milk, artificial human, 606 

ass', analysis of, 597 

condensed, 605 

cow's, analysis of, 597 

cause of indigestibility of, 597 
various ways of preparing, 604 

goat's, analysis of, 597 

human, analysis of, 597 

occasional indigestion of, 599 

pancreatised, 606 

preserved, danger of, 606 
Miliaria from sweating, 136 
Molluscum contagiosum, 796 

diagnosis of, 797 

morbid anatomy of, 796 

symptoms of, 796 

treatment of, 796 
Morphia, hypodermic injection of, in chol- 
eraic diarrhoea, 645 

in acute peritonitis, 691 
Mouth, examination of, 13 
Movements, cautious, in spinal caries, 158 

in tubercular peritonitis, 694 
Mucous disease after whooping-cough, 121 
Mucous flux in pertussis, 121 
Mucous membrane, sloughing of, in dysen- 
tery, 649 

membrane, syphilitic disease of, 204 
Mucous patches in inherited syphilis, 204 

in inherited syphilis, treatment of, 
215 
Mumps, 65 

deafness from, 66 

diagnosis of, 67 

facial paralysis from, 67 

infection, duration of, 67 

metastasis of, 66 

morbid anatomy of, 65 

sequelae of, 66 

symptoms of, 65 

temperature of, 65, 66 



Mumps, treatment of, 67 
Murmurs, cardiac, from valvular disease 
of the heart, 549 



in anaemia, 



m 



in chorea, 303 
Muscle, atrophy of, after chorea, 303 
in chronic hydrocephalus, 343 
in rickets, 134 
Muscle, morbid changes in, in infantile 
spinal paralysis, 376 
in pseudo-hypertrophic paralysis, 384 
in rickets, 134 
Muscles, contraction of, in infantile spinal 
paralysis, 376 
in pseudo-hypertrophic paralysis, 386 
Muscles, massage of, m anaemia, 235 
in chorea, 306 
spasm of, in spastic spinal paralysis, 
381 

Narcotics a cause of constipation in ba- 
bies, 617 
Nasal diphtheria, 98 

treatment of, 105 
Nasal line, significance of, 7 

obstruction in inherited syphilis, 
209 
Navel, haemorrhage from the, 656, 717 
Neck, stiffness of, in caries of cervical ver- 
tebras, 178 

in retro-pharyngeal abscess, 592 

in rheumatism, 159 
Necrosis, strumous, diagnosis of, 212 
Nematode worms, 705 
Nephritis, acute desquamative, 39 

acute parenchymatous, in inflamma- 
tory diarrhoea, 630 
Nervous system, diseases of, 260 

irritability of, in infancy, 2 
in rickets, 142 
Nettlerash (see Urticaria), 785 
Night terrors, cause of, 121, 560 

treatment of, 562 
Nipple, position of, in childhood, 551 
Nitrate of silver in chronic diarrhoea, 641 

in ulceration of bowels, 667 
Nodules, fibroid, in acute rheumatism, 160 
Noma (see Cancrum Oris\ 567 
Nose, shape of, in inherited syphilis, 211 
Nutrition, danger of sudden arrest of, 4 

dependence of, upon j ust selection of 
food, 596 

functions of blood in, 229 

ia anaemia, 229 

of paralysed limbs in infantile spinal 
paralysis, 373 
Nystagmus, causes of, 261 

in cerebrospinal fever, 70 

in chronic hydrocephalus, 343 

in congenital cataract, 261 

in idiocy, 396 

in tubercular meningitis, 360 

in tumour of brain, 261 

Oatmeal for constipated infants, 604, 621 
Obstruction of bowels, causes of, 668 



832 



INDEX. 



Occipital headache in cerebellar tumour, 
337 

in spinal caries, 178 
(Edema from cardiac dilatation, 547 

in ascites, 701 

in ague, 149 

in amyloid disease, 732 

in anaemia, 232 

in Bright's disease, acute, 39 
chronic, 754 

in chronic diarrhoea, 634 

in enlarged bronchial glands, 181 
mesenteric glands, 184, 226 
spleen, 238 

in fibroid induration of lung, 477 

in peri- typhlitis, 680 

in sarcoma of kidney, 771 

in scarlet fever, 39 

in suppurative pericarditis, 157 

interstitial, of lung, 39 

of brain in chronic hydrocephalus, 342 
(Edema of legs from enlarged glands in 
abdomen, 184, 226 

in acute tuberculosis, 195 

in amyloid liver, 732 

in chronic valvular disease of heart, 
547 

in congenital heart disease, 538 

in dysentery, 649 

in leucocythemia, 218 

in purpura, 250 

in tubercular peritonitis, 696 
(Edema of new-born infants, 808 

diagnosis of, 808 

treatment of, 809 
Oidium albicans in thrush, 572 

seat of. 572 
Oil, external application of, 18 
Oligsemia, 231 

Ophthalmoscopic examination in chronic 
hydrocephalus, 343 

in tubercular meningitis, 359 

in tumour of brain, 332 
Opisthotonos in infantile tetanus, 310 
Opium in treatment of dysentery, 651 

of inflammatory diarrhoea, 638 
Opium, susceptibility to, in early life, 18 
Optic neuritis in chronic Bright's disease, 
755 

in chronic hydrocephalus, 343 

in idiopathic ansemia, 233 

in tubercular meningitis, 359 

in tumour of brain, 332, 338 
Orange juice in treatment of scurvy, 258 
Orthopncea as a sign of external pressure 
on larynx. 420 

in catarrhal pneumonia, 437 

in retro- pharyngeal abscess, 592 
Ossification in rickets, 132 

of skull in chronic hydrocephalus, 341 
in cretinism, 393 
Osteochondritis, syphilitic, 206 
Osteomalacia and rickets, 135 
Otitis, 345 

acute, symptoms of, 348 

caries of petrous bone from, 368 



Otitis, causes of, 345 

chronic, symptoms of, 348 

consequences of, 347, 368 

diagnosis of, 352 

earache from, 348 

facial paralysis from, 368 

from follicular pharyngitis, 579 

from teething, 560 

in measles, 25 

in scarlet fever, 40 

in small -pox, 59 

latent, 348 

morbid anatomy of, 347 

prognosis in, 354 

treatment of, 1 89, 354 
Otorrhoea, chronic, treatment of, 189, 354 
Oxalate of lime calculi, 764 
Oxalate of lime in urine in cases of ic- 
terus neonatorum, 716 

in urine of rickety children, 134 
Oxyuris vermicularis, 705 

description of, 705 

seat of, 705 

symptoms of, 709 

treatment of, 711 

Pain in chest from foreign body in air- 
tubes, 528 

from spinal caries, 178 
Paint, white, as an application in erysip- 
elas, 113 
Palate, the V-shaped, in idiocy, 396 
Palpation of chest, 401 
Palpitation, cardiac, in anaemia, 232 

in cyanosis, 538 
Pancreas, secretion of, deficient in early 

infancy, 598 
Pancreatised milk, 606 
Paracentesis thoracis, 457 
Paralysis, acute infantile spinal, 371 

causation of, 871 

club-foot in. 376 ' 

complete recovery from, 374 

contraction of limbs in, 376 

diagnosis of, 377 

diet in, 378 

electricity, value of, in, 378 

genu recurvatum in, 376 

influence of teething on, 371 

mode of production of contractions in, 
375 

morbid anatomy of, 372 

partial recovery in, 374 

prognosis in , 377 

retarded growth of bone in, 373 

stage of contraction in, 375 

state of muscles in, 373 

sudden onset of, 373 

symptoms of, 373 

test of possible recovery in, 377 

treatment of, 378 

warmth, value of, in, 378 
Paralysis, cerebral, diagnosis of, 377 
Paralysis, diphtheritic, 99 

diagnosis of, 100 

pathology of, 93 



INDEX. 



883 



Paralysis, diphtheritic, prognosis in, 103 

symptoms of, 99 

treatment of, 107 
Paralysis from haemorrhage into cord, 377 

from pressure of growths on cord, 
226 

hysterical, 265 
Paralysis of diaphragm, 100 
diagnosis of, 102 

of face, 367 

of gullet, 100 

of heart, 99 

of limbs from diphtheria, 100 

of pharynx, 100 

of portio dura, 367 

of soft palate, 368 

of tongue and lips, 100 
Paralysis, pseudo-hypertrophic, 384 

atrophy of muscle in, 386 

causation of, 384 

contraction of muscle in, 386 

course of, 387 

diagnosis of, 387 

duration of, 387 

hypertrophy of muecle in, 384, 385 

morbid a q atomy of, 384 

prognosis in, 388 

symptoms of, 385 

temperature in. 386 

treatment of, 388 

weakness of muscles in, 385 
Paralysis, spasmodic spinal, 380 

causation of, 381 

contractions in, 382 

diagnosis of, 382 

difficulty of walking in, 381 

morbid anatomy of, 381 

often congenital, 381 

peculiarity of gait in, 382 

rigidity of joints in, 381 

symptoms of, 381 

treatment of, 382 
Paralysis, syphilitic, of arms, 210 

temporary, at onset of small-pox, 56 
Parasitic skin diseases, 798 
Parotiditis (see Mumps), 65 
Paroxysm of whooping-cough, description 

of, 116 
Paroxysmal dyspnoea (see Dyspnoea, Par- 
oxysmal), 519 
Pelvis, deformity of, in rickets, 139 
Pemphigus, 779 
Pepsin for habitu \l constipation, 622 

in treatment of chronic diarrhoea, 640 
Percussion of chest, 402 
Perforation of bowel in enteric fever, 81 

in peri-typhlitis, 679 
Pericarditis, rheumatic, 155 

auscultatory signs of, 156 

cerebral symptoms in, 159 

diagnosis of, 161 

iodide of potassium in, 165 

morbid anatomy of. 154 

physical signs of, 156 

symptoms of, 155 

treatment of, 165 
53 



Pericarditis, suppurative, 157 

diagnosis of, 162 

oedema of legs in, 157 

physical signs of, 157 

symptoms of, 157 

temperature in, 157 

treatment of, 165 
Pericardium, adhesion of, 546, 550 
Periosteogenesis, syphilitic, 206 
Peritonitis, acute, ascites in, 687 

causation of, 685 

diagnosis of, 689 

from perforation of bowel, 688 

in erysipelas, 111, 686 

latent form of, 688 

morbid anatomy of, 686 

pains in, 687 

prognosis in, 691 

secondary, 688 

to pleurisy, 453 

symptoms of, 686 

temperature in, 687 

treatment of, 691 

vomiting in, 687 
Peritonitis, tubercular, 693 

acute form of, 696 

diagnosis of, 697 

diet in, 699 

insidious beginning of, 694 

morbid anatomy of, 693 

prognosis in, 698 

shape of belly in, 695 

symptoms of, 694 

temperature in, 696 

tenderness of belly in, 694 

treatment of, 698 
Peri-typhlitis, 678 

causation of, 678 

diagnosis of, 683 

morbid anatomy of, 678 

prognosis in, 683 

simulation of hip-joint disease by, 680 

suppuration in, 680 

.symptoms of, 679 

treatment of, 684 
Peroxyde of hydrogen in treatment of 

cyanosis, 543 
Pertussis (see Whooping-cough), 109 
Petechias from embolisms in cutaneous 
vessels, 158, 552 

in anaemia, 233 

in asthenic measles, 24 

in atrophic cirrhosis of liver, 728 

in cerebro-spinal fever, 69, 70 

in haemophilia, 2-13 

in hypertrophic cirrhosis of liver, 729 

in lymphadenoma, 224 

in malformation of bile-ducts, 717 

in malismant diphtheria, 97 
small-pox, 60 

in melaena neonatorum, 656 

in purpura, 248 

in scurvy, 256 

in ulcerative endocarditis, 158 

in umbilical phlebitis, 719 
Petrous bone, caries of, 368, 540 



834 



INDEX. 



Pharyngitis, catarrhal, 576 

causation of, 576 

diagnosis of, 577 

symptoms of, 576 

treatment of, 577 
Pharyngitis, follicular, 578 

causation of, 578 

cauterisation in, 580 

deafness in, 579 

diagnosis of, 579 

morbid anatomy of, 578 

prognosis in, 579 

symptoms of, 578 

treatment of, 579 
Pharyngitis, herpetic, 580 

causation of, 580 

diaguosis of, 580 

symptoms of, 580 

treatment of, 581 
Pharyngitis, tubercular, 581 

diagnosis of, 582 

morbid anatomy of, 581 

prognosis in, 583 

symptoms of, 581 

treatment of, 583 
Pharynx, paralysis of, 100 
Pharynx, scald of, 576 

symptoms of, 577 

treatment of, 578 
Phthisis, acute, 505 

diagnosis of, 507 

dyspnoea in, 506 

physical signs of, 506 

prognosis in, 508 

symptoms of, 505 

temperature in, 506 

treatment of, 516 

wasting in, 506 
Phthisis, chronic pneumonic, 508 

cough in, 509 

diagnosis of, 513 

physical signs of, 509, 510 

prognosis in, 515 

secondary catarrhal pneumonia in, 510 

symptoms of, 508 

temperature in, 510 

treatment of, 516 
Phthisis, chronic tubercular, 511 

diagnosis of, 513 

prognosis in, 515 

symptoms of, 511 

treatment of, 516 
Phthisis, pulmonary, 502 

causation of, 502 

morbid anatomy of, 504 

treatment of, 516 

varieties of, 502 
Phthisis simulated by attacks of recurring 
catarrh, 483, 611 

tuberculo-pneumonic. 511 
Pigeon- breast from permanent collapse of 
lower lobes of lungs, 400 

in rickets, 189 
Pitting- of skin after varicella, 49 

after variola, 59 
Pleurisy, 444 



Pleurisy, aspiration of fluid in, 457 

causation of, 444 

characters of effusion in, 444 

complexion in, 446 

complications of, 453 

diagnosis of, 453 

diaphragmat c, 452 

diet in, 457 

exaggerated symptoms in, 449 

friction-sound in, 449 

loculated, 452 

morbid anatomy of, 444 

often conjoined with pericarditis, 158 

onset of, 445 

pain in, 446 

perforation of bronchus in, 450 
of chest-wall in, 450 

physical signs of, 447 

plastic, 452 

prognosis in, 455 

resection of rib in, 460 

rheumatic, 158 

spontaneous evacuation of fluid in, 
450 

sudden death in, 458 

symptoms of, 445 

temperature in, 446 

terminations of, 449 

treatment of, 456 

tuberculous, 452 

use of drainage-tube in, 459 

varieties of, 451 
Pneumonia, catarrhal, 434 

breathing in, 437 

causation of, 434 

complications of, 439 

cough in. 437 

counter- irritation in, 442 

diagnosis of, 439 

diet in, 442 

dilated bronchi in, 439 
diagnosis of, 441 

dyspnoea in, 437 

favourable ending in, 438 

in diphtheria, 98 

in measles, 25 

in pulmonary tuberculosis, 196 

in whooping-cough, 120 

iron in treatment of, 443 

mode of death in, 438 

morbid anatomy of, 434 

physical signs of, 437 

prognosis in, 441 

pulse-respiration ratio in, 437 

stimulants in treatment of, 442 

subacute course of, 438 

symptoms of, 436 

temperature in, 436 

tepid baths in treatment of, 441 

treatment of, 441 
Pneumonia, cerebral, 262, 425 
Pneumonia, croupous, 422 

abscess of lung in, 429 

bleeding, occasional value of, in, 433 

breathing in, 426 






INDEX. 



835 



Pneumonia, croupous, complications of, 430 

crisis of, 429 

delirium in, 425 

diagnosis of, 430 

diet in, 432 

facies of, 425 

headache in, 425 

jaundice in, 430 

latent, 429 

morbid anatomy of, 423 

muscular weakness in, 425 

nature of, 422 

nervous symptoms in, 425 

occasional alarming symptoms in, 427 

onset of, 424 

physical signs of, 427 

prognosis in, 431 

pulse-respiration ratio in, 426 

quinine in treatment of, 432 

reduction of pyrexia in, 432 

stimulants, indication for, in, 433 

symptoms of, 424 

temperature in, 427 

terminations of, 428 

treatment of, 532 

urine in, 426 
Pneumo-thorax from rupture in inter- 
lobular emphysema, 492 

from rupture in pulmonary gangrene, 
499 
Portio dura, paralysis of, 367 

causes of, 367 

deafness in, 370 

diagnosis of, 369 

flattening of arch of palate in, 368 

from neglected otitis, 368 

impairment of taste in, 368 

inability to whistle in, 368 

otorihoea in, 370 

prognosis in, 369 

symptoms of, 368 

treatment of, 370 
Potash, chlorate of, in treatment of ulcer- 
ative stomatitis, 566 
Prolapse of rectum from straining in mic- 
turition, 748 
Prophylaxis in scarlet fever, 43 
Prurigo, 778 
Psoriasis, 780 
Puerperal erysipelas, 109 
Pulse during sleep in infants, 9 

in acquired hydrocephalus, 344 

in aortic regurgitant disease not char- 
acteristic, 550 

in atrophic cirrhosis of liver, 729 

in capillary bronchitis, 484 

in cerebral haemorrhage, 327 
tumour, 333 

in cerebro- spinal fever, 71 

in congenital heart disease, 538 

in diphtheria, 102 

in encephalitis, 351 

in enteric fever, 79 

in gangrene of lung, 498 

in infants, 9 

in inflammatory diarrhoea, 631 



Pulse in intussusception, 673 

in leucocythemia, 218 

in measles, 24 

in megrim, 295 

in oedema of new-born infants, 808 

in peritonitis, acute, 687 

in peri-typhlitis, 680 

in pneumonia, catarrhal, 437 
croupous, 426 
tuberculous, 197 

in purulent meningitis, 349 

in scarlet fever, 34 

in sclerema, 807 

in spasm of pertussis, 116 

in spurious hydrocephalus, 632 

in tetanus, 312 

in tubercular meningitis, 359, 361 

slow, as indicating cardiac failure, 99 

slow, in convalescence from acute dis» 
ease, 265 

slow, significance of, 265 
Pulse-respiration ratio in capillary bron- 
chitis, 483 

in catarrhal pneumonia, 437 

in collapse of lung, 467 

in croupous pneumonia, 426 

in pleurisy, 453 
Pupils in acquired hydrocephalus, 344 

in purulent meningitis, 349 

in tubercular meningitis, 359 

inequality of, significance of, 261 
Purgatives, abuse of, 19 
Purgatives, value of, in acute Bright's dis- 
ease, 46 

in anaemia, 234 

in chronic Bright's disease, 761 

in quinsy, 5 89 

in valvuh 
Purpura, 247 

anaemia in, 250 

aperients for, 252 

causation of, 247 

cerebral haemorrhage in, 251 

convulsions in, 251 

diagnosis of, 251 

eruption of, 248 

haemorrhagica, 249 

heart murmur in, 250 

in chronic Bright's disease, 755 

morbid anatomy of, 247 

oedema in, 249 

pains in limbs in, 249 

pathology of, 248 

prognosis of, 251 

rheumatica, 249 

simplex, 248 

symptoms of, 248 

temperature in, 250 

treatment of, 251 
Pyelitis from calculus of kidney, 766 
Pylocarpine in treatment of chronic bron 
chitis, 489 

in treatment of uraemia, 47 
Pyrexia (see Temperature) 

from catarrh in scrofulous children, 
177 



836 



INDEX. 



Pyrexia from entrance of organic particles 
into circulation, 552 
from rapid growth, 11 
of teething, 558 
secondary in enteric fever, 82 
in small-pox, 58 

Quinine, hypodermic injection of, in ague, 
151 

in treatment of croupous pneumonia, 

482 
in treatment of whooping-cough, 125 
large doses of, for acute eczema, 795 
for chronic urticaria, 786 
Quinsy, causation of, 584 
deafness from, 585 
diagnosis of, 588 
morbid anatomy of, 585 
nasal quality of voice in, 585 
non-suppurative form of, 586 
prognosis in, 588 
prostration in, 586 
symptoms of, 585 
temperature in, 585 
treatment of, 588 

Rash, bromide, 292 

of acute tuberculosis, 195 

of belladonna, 783 

of cerebro-spinal fever, 70 

of chicken-pox, 48 

of dentition, 560 

of eczema, 790 

of enteric fever, 77 

of epidemic roseola, 30 

of erysipelas, 110 

of erythema, 782 

of infantile syphilis, 209 

of measles, 22 

of purpura, 248 

of roseola, 787 

of scarlet fever, 34 

of small-pox, 57 

of teething, 560 

of urticaria, 785 

of varioloid, 61 
Raw meat in treatment of chronic diar- 
rhoea, 640 

mutton juice, 258 
Rectum, polypus of, 656 

diagnosis of, 658 

symptoms of, 657 

treatment of, 659 
Rectum, prolapse of, from straining at 
stool, 619 

from worms, 709 

in diarrhoea, 632 

treatment of, 639 

in passing water, 197 
Reflex convulsions, 277 
Relapse of enteric fever, 82 

of infantile syphilis, 211 

of measles, 25 

of rheumatic fever, 155 

of stridulous laryngitis, 411 
Remedies, internal, 18 



Renal inadequacy, 758 

after enteric fever, 82 
treatment of, 760 
Resonance, vocal, value of, 405 
Respiration, frequency of, in infancy (see 

Breathing), 110 
Respiratory movements in the infant, 12 
Retention of urine in enteric fever, 78 

in tubercular meningitis, 359 
Retraction of head (see Head, Retraction 

of) 
Retro-pharyngeal abscess, 591 

acute form of, 593 

causation of, 591 

chronic form of, 593 

cough in, 592 

diagnosis of, 594 

from membranous croup, 594 
from oedema of glottis, 594 

duration of, 593 

dysphagia in, 592 

prognosis in, 595 

stiffness of neck in, 592 

swelling of neck in, 592 

symptoms of, 592 

treatment of, 595 

tumour of pharynx in, 592 

voice in, 592 
Rheumatism, acute, 153 

causation of, 153 

cerebral symptoms in, 159 

chronic, 160 

consequences of, 163 

convulsions in, 159 

delirium in, 159 

diagnosis of, 161 

diet in, 164 

duration of, 160 

endocarditis in, 158 

fibroid nodules in, 160 

heart affection in, 155 

joint affection in, 155 

morbid anatomy of, 154 

muscular, treatment of, 165 

of abdominal muscles, 159 

pericarditis in, 155 

pneumonia in, 159 

prognosis in, 162 

relapses in, 160 

salicylate of soda in treatment of, 163 

symptoms of, 154 

temperature in, 154 

torticollis in. 159 

treatment of, 163 
Rheumatism, scarlatinous, 38 

treatment of, 46 
Ribs, beading of, in rickets, 139 

resection, of, in pleurisy, 460 

thinning of, in scurvy, 254 
Rigidity of joints (see Joints, Rigidity of) 
Ringworm, 801 

of the scalp (see Tinea Tonsurans), 799 
Roseola, 786 

diagnosis of, 786 

epidemic (see Epidemic Roseola), 30 

symptoms of, 785 



INDEX. 



837. 



Roseola, treatment of, 786 
Rotheln (see Epidemic Roseola), 30 
Roundworm (see Ascaris Lumbricoides) 705 

Salicylate of soda in treatment of acute 
rheumatism, 163 

in treatment of quinsy, 588 
Saliva, scanty secretion of, in early in- 
fancy, 598 

value of, in digestion, 598 
Sand, uric acid, in urine, 757, 760, 763 
Scabies, 798 

diagnosis of, 799 

symptoms of, 798 

treatment of, 799 
Scald of larynx, 407 

of pharynx, 576 
Scarlet fever, 32 

abscesses in, 40 

albuminuria in, 39 

complications of, 37 

coryza of, 38 

diagnosis of, 41 

diarrhoea in, 38 

diphtheria in course of, 38 

duration of infective period of, 32 

gangrene in, 40 

infective period, duration of, in, 32 

latent, 40 

malignant, 36 

morbid anatomy of, 33 

nephritis, albuminous, after, 39 

nervous symptoms of, 36 

oedema in, 39 

otorrhoea in, 40 

prognosis of, 41 

rash of, 34 

rheumatism in, 38 

stage of desquamation of, 36 
of eruption of, 34 
of incubation of, 33 
of invasion of, 34 

symptoms of, 33 

temperature in, 34, 35 

throat affection in, 35, 37 

treatment of, 43 

urgemia in, 39 

urine in, 39 

varieties of, 34 
Sclerema, 806 

adiposa, 806 

duration of, 808 

morbid anatomy of, 806 

symptoms of, 807 

temperature in, 807 

treatment of, 809 
Scolices of taenia echinococcus, 738 
Scrofula, 173 

bone disease in, 178 

bronchial glands, caseation of, 180 

causation of, 173 

climate in treatment of, 187 

cold bathing in treatment of, 188 

cutaneous abscesses in, 177 

deafness from, 177 

diagnosis of, 185 



Scrofula, diet in, 187 

glandular lesions in, 175, 179 

mesenteric glands, caseation of, 183 

morbid anatomy of, 174 

otorrhoea in, 177 

treatment of, 189 

ozaena in, 177 

pharyngeal catarrh in, 177 

prognosis in, 186 

pulmonary catarrh in, 177 

skin affections in, 177 

spine, disease of, in, 178 

symptoms of, 175 

tendency to catarrh in, 176 

treatment of, 187 
Scurvy, 253 

anaemia in, 256 

causation of, 253 

connection of, with rickets, 253 

diagnosis of, 257 

gums in, 256 

morbid anatomy of, 254 

orange juice in treatment of, 258 

pathology of, 255 

prognosis in, 258 

separation of epiphyses in, 256 

swelling of limbs in, 256 

symptoms of, 255 

temperature in, 257 

tenderness in, 256 

treatment of, 258 
Seat-worm (see Oxyuris Vermicularis), 705 
Secondary pyrexia in enteric fever, 82 

in small-pox, 58 
Senses, development of, in healthy in- 
fancy, 395 

dulness of, in idiocy, 394 
in lymphadenoma, 224 
Sewer gas a cause of croupous pneumonia, 
423 

of diphtheria, 90 

of enteric fever, 74 

of inflammatory diarrhoea, 629 

of quinsy, 584 
Sight, impairment of, in Bright's disease, 
755 

in cerebral disease, 261 

in cerebral tumour, 332 

in chronic hydrocephalus, 343 

in idiocy, 394 
Silver, nitrate of, in treatment of chronic 

diarrhoea, 641 
Skin, diseases of, 778 

dryness of, in cyanosis, 539 
in infantile atrophy, 600 

earthy tint of, in atrophic cirrhosis of 
liver, 728 

earthy tint of, in chronic abdominal 
derangement, 11 
Skin, harshness of, in acute tuberculosis, 
195 

in atrophic cirrhosis of liver, 728 

in chorea, 305 

in cyanosis, 539 

in lymphadenoma, 224 

in renal disease, 759 



838 



INDEX. 



Skin, harshness of, in cirrhosis of liver, 
728 

in cretinism, 396 
inelasticity of, in renal disease, 11, 759 
in severe thrush, 573 
in syphilitic infants, 211 
in tuberculosis, 195 
staining of, after birth, 714 
Skull, auscultation of, in rickets, 138 
Skull, shape of, in chronic hydrocephalus, 
343 
in idiocy, 396 
in rickets, 137 
in infantile syphilis, 208 
Small-pox, 55 

complications of, 59 
confluent, 60 
diagnosis of, 61 
discrete, 60 

duration of infection in, 55 
malignant, 60 
modified, 61 
morbid anatomy of, 55 
papular stage of, 57 
prognosis in, 62 
pustular stage of, 57 
secondary fever in, 58 
stage of decline, 58 
of eruption, 56 
of invasion, 56 
of maturation, 57 
symptoms of . 56 
temperature in, 56, 58, 61 
treatment of, 62 
varieties of, 60 
varioloid, 61 
vesicular stage, 57 
Snoring from enlarged tonsils, 587 

from paralysis of soft palate, 100 
Snuffling in inherited syphilis, 209 
Softening of caseous glands, 175 
Sore throat in diphtheria, 93 
in enteric fever, 78 
in follicular pharyngitis, 578 
in herpes of the pharynx, 580 
in measles, 22 
in mumps, 66 
in quinsy, 585 
in scarlet fever, 34, 37 
in tubercular pharyngitis, 581 
Sounds, breath-, conducted by chest-wall, 

404 
Spasm of larynx (see Laryngismus Stri- 
dulus), 411 
in whooping-cough, 118 
Spasmodic laryngitis (see Laryngitis Stri- 

dulosa), 411 
Spinal cord, hgemorrhage into, 377 
in infantile spinal paralysis, 380 
in tetanus, 309 
Spinal paralvsis, infantile (see Paralysis, 
Infantile Spinal), 371 
spasmodic (see Paralysis, Spasmodic 
Spinal), 380 
Spine, caries of, 178 
attitudes in, 178 



Spine, caries of, diagnosis of, 185 

pain in chest from, 178 

stiffness in back from, 178 

symptoms of, 178 
Spine, deformity of, in rickets, 139 

ether spray to, in treatment of chorea, 
306 
Spleen, chronic congestion of, 134 

embolism of, 158, 237 
Spleen, enlargement of, 237 

causes of, 237 

in ague, 148 

in atrophic cirrhosis of liver, 728 

in congenital heart disease, 539 

in congenital malformation of bile- 
ducts, 717 

in rickets, 133 
Spleen, extirpation of, 219 

faradisation of, 219 

in leucocythemia, 216 

in lymphadenoma, 221 

mode of examining, 237 
Spleen, simple hypertrophy of, 238 

angemia in, 238 

blood in, characters of, 238 

clothing in, 241 

complexion in. 238 

diagnosis of, 240 

epistaxis in, 238 

morbid anatomy of, 238 

oedema in, 238 

perverted appetite in, 238 

petechias in, 238 

prognosis in, 240 

symptoms of, 238 

treatment of, 240 
Spleen, syphilitic disease of, 205 

tubercular disease of, 193 
Spotted fever (see Cerebro spinal Fever), 68 
Sprays, antiseptic, in diphtheria, 104 

in gangrene of lung, 500 

in pulmonary phthisis, 518 

in whooping-cough, 126 
Sprays, ether, to spine in treatment of cho- 
rea, 306 
Squint following convulsions, 261 

from hypermetropia, 261 

from pressure on third nerve, 226, 
332 

in cerebral paralysis, 377 

in cerebro-spinal fever, 71 

in chronic hydrocephalus, 343 

in diphtheria, 100 

in encephalitis, 351 

in purulent meningitis, 349 

in tubercular meningitis, 359 

in tumour of brain, 332 

significance of, 261 
Staggering gait in cerebellar tumour, 337 
Starch, difficulty of digesting, in chronic 
diarrhoea, 640 

in infancy, 596 

in rickets, 145 
Steam-draught inhaler, Dr. Lee's, 126 
Stethoscope, value of, 403 
Stimulants, value of, 18 



INDEX. 



839 



Stomach-tube for forced feeding of in- 
fants, 15 
Stomatitis, aphthous, 563 

causation of, 563 

diagnosis of, 564 

prognosis in, 564 

symptoms of, 563 

temperature in, 564 

treatment of, 564 
Stomatitis, gangrenous, 567 

causation of, 567 

diagnosis of, 569 

diet in, 569 

disinfectants in treatment of, 570 

morbid anatomy of, 567 

prognosis in, 569 

stimulants in treatment of, 569 

symptoms of, 568 

treatment of, 569 
Stomatitis, simple, 559 
Stomatitis, ulcerative, 564 

causation of, 564 

chlorate of potash in treatment of, 566 

diagnosis of, 566 

diet in, 566 

duration of, 565 

in lymphadenoma, 224 

local applications for. 566 

prognosis in, 566 

symptoms of, 565 

temperature in, 565 

treatment of, 566 
Stools, appearance of, in choleraic diar- 
rhoea, 643 

in chronic diarrhoea, 633 

in congestion of liver, 723 

in dysentery, 649, 650 

in inflammatory diarrhoea, 631 

in simple diarrhoea, 626 

in tubercular peritonitis, 696 

in ulceration of bowels, 662 
Stridor, respiratory, from pressure on 

trachea, 182 
Strophulus, 779 
Stupor at the onset of small-pox, 56 

from hyper-pyrexia in acute rheuma- 
tism, 159 

from indigestion, 2 

in acquired hydrocephalus, 344 

in ague, 149 

in asthenic measles, 24 

in Bright's disease, acute, 39 
chronic, 755 

in cerebro-spinal fever, 69 

in congestion of brain, 318 

in convulsions, 280 

in encephalitis, 351 

in epilepsy, 288 

in haemorrhage into brain, 324 

in hypertrophic cirrhosis of liver, 729 

in malignant diphtheria, 97 
scarlet fever, 36 
small-pox, 60 

in purulent meningitis, 349 

in tubercular meningitis, 360 

in umbilical phlebitis, 719 



Stupor in urasmia, 39 

significance of, 262 
Swallowing difficult in infantile tetanus, 
310 
in post-natal atelectasis, 476 
in retro-pharyngeal abscess, 592 
in suppuration about larynx, 419 
Swallowing, loss of power in, in diphthe- 
ria, 94 
painful in diphtheria, 94 

in follicular pharyngitis, 578 
in quinsy, 586 

in tubercular pharyngitis, 582 
peculiarities of, in idiocy, 396 
Sweating of head in rickets, 138 

treatment of, 145 
Syncope, diagnosis of, from epilepsy, 290 
from flatulent distention, 121, 612 
in anaemia, 232 

in congenital heart disease, 539 
in chronic valvular disease of heart, 

547 
in purpura hemorrhagica, 251 
Syphilis conveyed by vaccination, 54 
Syphilis, infantile, 202 

affection of bones in, 206 
of glottis in, 204 
of heart in, 205 
of liver in, 205 
of lungs in, 204 
of mucous membranes in, 204 
of spleen in, 206 
amyloid degeneration from, 211, 731 
cranio-tabes in, 210 
cry in, 210 
diagnosis of, 211 
diet in, 214 

epilepsy resulting from, 211 
eruption in, 209 
mode of infection in, 202 
morbid anatomy of, 203 
mucous tubercles in, 209 
paralysis of arms in, 210 
prognosis in, 213 
pseudo -paralysis in, 210 
relapses in, '211 
snuffling in, 209 
state of nutrition in, 211 
symptoms of, 208 
treatment of. 213 
Syringe-feeder, the, 15 

Tabes mesenterica, 183 
Taenia (see Tape-worm), 706 

echinococcus, 737 

medio-cannellata, 706 

solium, 706 
Talking in sleep in cases of indigestion, 612 

usual age for beginning, 396 
Tape- worm. 706 

seat of. 707 

symptoms of, 711 

treatment of, 712 
Tapping the chest, 457 

the pericardium, 165 
Tar in treatment of chronic bronchitis, 4S9 



840 



INDEX. 



Taste blunted in idiocy, 394 

impaired in follicular pharyngitis, 579 

in paralysis of portio dura, 368 
Teeth, the milk, 556 

incompleteness of, 557 
order of eruption of, 557 
retention of, into adult life, 560 
supernumerary, 557 
times of cutting, 556 
Teeth, the permanent, notching of, in in- 
fantile syphilis, 211 
order of cutting, 560 
Teething, complications of, 558 
derangements of, 555 

diagnosis of, 561 

treatment of, 562 
diarrhoea of, 559 

treatment of, 562 
early, in infantile syphilis, 200 

in tubercular children, 556 
influence of, upon general health, 555 
late in rickets, 138 
pyrexia of, 558 
retarded, 557 
symptoms of, 558 
Temper, changes in, significance of, 262 
irritability of, from acid dyspepsia, 
611 
Temperature in acute rheumatism, 154 
in ague, 148 

in anasmia, idiopathic, 233 
in atelectasis, congenital, 462 

post-natal, 467 
in atrophy, infantile, 602 
in bowels, ulceration of, 663 
in brain, congestion of, 319 

haemorrhage into, 324 

tumour of, 335 
in Bright's disease, acute, 39 
in bronchial glands, enlargement of, 

180 
in bronchitis, capillary, 483, 484 
in cancrum oris, 568 
in cerebral apoplexy, 324 

congestion, 319 

sinuses, thrombosis of, 351 
in cere bro- spinal fever, 70 
in chicken-pox, 48 
in chorea, 303 
in cyanosis, 538 
in dentition, 558 
in diarrhoea, choleraic, 643 

inflammatory, 631 

simple, 626 
in diphtheria, 93, 95 
in dysentery, 650 
in encephalitis, 351 
in enteric fever, 79 
in epidemic roseola, 30 
in erysipelas, 351 
in fibroid induration of lung, 477 
in gangrene of lung, 498 

spontaneous, 170 
in gastric catarrh, 610 
in heart, congenital malformation of, 
538 



Temperature in hydrocephalus, acute, 358, 
359, 361 

spurious, 632 
in infancy, 10 

in infantile spinal paralysis, 373 
in intussusception, 670 
in laryngismus stridulus, 269 
in laryngitis, simple, 408 

stridulous, 4i2 

tuberculous, 416 
in leucocythemia, 218 
in lung, collapse of, 462, 470 

gangrene of, 498 
in lymph adenoma, 223 
in measles, 22 
in meningitis, purulent, 349 

tubercular, 358, 359, 361 
in mumps, 65 

in oedema of new-born infants, 808 
in paralysis, acute infantile spinal, 373 

pseudohypertrophic, 386 
in pemphigus, 779 
in pericarditis, 155 

suppurative, 157 
in peritonitis, acute, 687 

tubercular, 695 
in peri-typhlitis. 681 
in pharyngitis, catarrhal, 577 

tubercular, 582 
in phthisis, pulmonary, acute, 506 

chronic, 510 
in pleurisy, 446 
in pneumonia, catarrhal, 436 

croupous, 427 
in purpura, 250 
in quinsy, 585 
in rheumatism, 154 
in rheumatism of abdominal muscles, 

159 
in rickets, 141 
in scarlet fever, 34, 35 
in sclerema, 808 
in scrofula, 181 
in scurvy, 257 
in small- pox, 56, 58, 61 
in stomatitis, aphthous, 563 

simple, 559 

ulcerative, 565 
in teething, 558 
in tetanus, 310 
in tetany, 275 
in thrush, 574 
in tuberculosis, 195 
in tumour of brain, 335 
in typhlitis, 679 
in ulceration of bowels, 663 
in ulcerative stomatitis, 565 
in varicella, 48 
in variola, 56, 58, 61 
in whooping-cough, 115 
reduction of, in hyper-pyrexia, 15 
sub-normal, clinical value of, 11 
in atelectasis, congenital, 462 

post-natal, 467 
in convalescence from acute disease, 11 
in cyanosis, 538 



INDEX. 



841 



Temperature in fasting infants, 10 

in infantile atrophy, 602 
Tenderness, general, in scurvy, 256 

in severe rickets, 137 
Tenesmus in cases of colitis, 632 

of colitis, treatment of, 638 

of dysentery, 649 

of intussusception, 670 

of polypus of rectum, 657 
Terrors, night, 121 

treatment of, 562 
Tetanus, idiopathic, 308 

calabar bean in treatment of, 313 

causation of, 308 

cessation of cry in, 310 

chloral in treatment of, 313 

diagnosis of, 312 

duration of, 311 

morbid anatomy of, 309 

opisthotonos in, 310 

prognosis in, 312 

rapid wasting in, 310 

sedatives in treatment of, 313 

spasms in, 310 

stiffness of jaws in, 310 

temperature in, 310 

tonic rigidity in, 310 

treatment of, 313 
Tetany (see Extremities, Tonic Contraction 

of), 274 
Thermometer, value of, 11 
Thirst, intense, in choleraic diarrhoea, 643 

signs of, in the infant, 8 
Throat, diseases of mouth and, 555 

inflammation of (see Pharyngitis), 576 

inspection of, 13 
Thrombosis of heart, 98 

treatment of, 108 

of cerebral sinuses (see Cerebral Sin- 
uses), 650 
Thrush, 571 

applications for, 575 

causation of, 571 

diagnosis of, 574 

diet in, 575 

general atrophy in, 572 ■ 

morbid anatomy of, 572 

necessity of cleanliness in treatment 
of, 575 

oidium albicans of, 572 

prognosis in, 574 

spurious hydrocephalus in, 573 

symptoms of, 573 

temperature in, 573 

treatment of, 574 
Thymus gland, syphilitic disease of, 205 
Thyroid body, absence of, in the cretin, 393 
Tinea circinata, 800 
Tinea favosa, 804 

diagnosis of. 805 

symptoms of, 804 

treatment of, 805 
Tinea tonsurans, 799 

croton-oil treatment of, 803 

diagnosis of, 801 

symptoms of, 800 



Tinea tonsurans, treatment of, 802 
Tongue, appearance of, in gastric catarrh, 
611 

in worms in the alimentary canal, 709 
Tongue, ulceration of, in whooping-cough, 

117 
Tonics, general value of, 18 
Tonsils, chronic enlargement of, 584 

alteration of features from, 587 

causation of, 584 

cough from, 588 

deafness from, 587 

effect of, on general health, 587 

hollow breathing from, 588 

morbid anatomy of, 585 

nasal voice from, 587 

symptoms of, 586 

treatment of, 589 
Tonsils, inflammation of (see Quinsy), 584 
Torticollis, rheumatic, 159 
Trachea, pressure on, causing stertor, 182 
Tracheotomy, accidents after, 107 

in membranous croup, 105 
Tremours in cerebral tumour, 333 

in enteric fever, 84 

in tubercular meningitis, 360 

significance of, 263 
Tricophyton tonsurans, 799 
Tube, stomach-, for forced feeding, 15 
Tubercular meningitis, 355 

abdomen in, 359 

anomalous cases of, 362 

breathing in, 359 

causation of, 355 

cerebral flush in, 359 

coma in, 360 

constipation in, 358 

convulsions in, 360 

deceptive improvement in, 360 

diagnosis of, 362 

from acute gastric catarrh, 364 
from cerebral pneumonia, 364 
from enteric fever, 83 
from malnutrition, 363 
from simple meningitis, 365 
from spurious hydrocephalus, 363 

drowsiness in, 359 

fontanelle, in, 360 

headache in, 358 

insidious beginning of, 363 

morbid anatomy of, 356 

nystagmus in, 360 

paralytic stage of, 360 

premonitory stage of, 357 

primary form of, 361 

prognosis in, 365 

pulse in, 358. 359, 361 

pupils in, 359 

retention of urine in, 359 

rigidity of joints in, 360 

secondary form of, 361 

squinting in, 359 

stage of invasion of, 358 
of irritation of, 359 

symptoms of, 357 

temperature in, 358, 359, 361 



842 



ITsTDEX. 



Tubercular meningitis, tongue in, 358 

treatment or', 365 

twitchings in, 360 

vomiting in, 358 
Tuberculosis, acute, 190 

bacillus of, 191 

causation of, 190 

diagnosis of, 198 

from acute gastric catarrh, 198 
from infantile atrophy, 199 
from typhoid fever, 83 

duration of, 198 

forms of, 190 

morbid anatomy of, 191 

oedema of legs in, 195 

onset of, 194 

physical signs of, 196 

prognosis in, 200 

reduction of pyrexia in, 200 

symptoms of, 194 

secondary to empyema, 453 

temperature in, 195 

treatment of, 200 
Tumour of brain (see Cerebral Tumour), 330 
Turpentine as an anthelmintic, 712 
Tympanic membrane, rupture of, in whoop- 
ing-cough, 118 
Tympanitis, treatment of, 692 
Typhlitis, 678 

causation of, 678 

diagnosis of, 682 

diet in, 684 

prognosis in, 683 

symptoms of, 679 

treatment of, 684 
Typhoid fever (see Enteric Fever), 74 

Ulceration of bowels (see Bowels, Ul- 
ceration of), 660 
Ulceration of mucous membrane in infan- 
tile syphilis, 2C4, 582 
in lymphadenoma, 222 
in ulcerative stomatitis, 565 
Ulceration of throat in diphtheria, 93 
in scarlet fever, 34. 37 
in tubercular pharyngitis, 581 
Ulceration of vocal cords in infantile syph- 
ilis, 2(J4 
in tubercular laryngitis, 416 
Ulceration, sub-lingual, in whooping-cough, 

117 
Ulcerative endocarditis, 154 

stomatitis (see Stomatitis, Ulcerative), 
564 
Umbilical arteritis, 718 
Umbilical phlebitis, 717 
diagnosis of, 720 
pathology of, 718 
prognosis in, 720 
symptoms of, 719 
treatment of, 720 
Umbilical vein, haemorrhage from, 654 
Umbilicus, hsemorrhag-e from, 656, 717 
Unconsciousness in infants, test of, 262, 

338 
Uraemia, blood in urine in, 33 



Uraemia, convulsions in, 282 
Ursemic poisoning, cause of, 33 

symptoms of, 39, 282, 756 

treatment of, 46 
Urea, excretion of, increased in croupous 
pneumonia, 4i6 

in the child, 745, 758 
Ureter, impaction of calculus in, 766 
Uric acid, formation of, in the urinary 
passages, 763 

in renal ducts a cause of hematuria, 
765 

in urine a cause of wetting of the 
bed, 748, 756, 765 

pain in urethra from, 765 
Urinary calculi, 763 

Urinary casts in acute desquamative ne- 
phritis, 39 

in chronic Bright 's disease, 755 

in passive congestion of kidney, 746 
Urinary deposits, 757, 758 
Urine, albumen in (see Albuminuria) 

blood in (see Haematuria) 

characters of healthy, 745 

flow of, a sign of recovery in convul- 
sions, 283 

in ascites, 701 

in acute generalised myelitis, 377 
phthisis, 506 
rheumatism, 154 
tuberculosis, 195 

in ague, 149 

in atrophic cirrhosis of liver, 727 

in Bright's disease, acute, 39 
chronic, 756 

in cerebro- spinal fever, 71 

in chorea, 303 

in congenital disease of heart, 539 

in cystitis, tubercular, 197 

in diphtheria, 95 

in dysentery, 649 

in enteric fever, 78 

in gastric catarrh, 611 

in hsemorrhagic purpura, 249 

in hydronephrosis, 772 

in hypertrophic cirrhosis of liver, 
728 

in icterus neonatorum, 716 

in infantile tetanus, 310 

in inflammatory diarrhoea, 633 

in leucocythemia, 224 

in measles, 24 

in membranous croup, 89, 414 

in pneumonia, croupous, 426 

in rheumatism of abdominal muscles, 
159 

in rickets, 134 

in sarcoma of kidney, 770 

in scarlet fever, 39 

in scurvy. 257 

in spontaneous gangrene, 170 

in thrush, severe cases of, 574 

in ulcerative endocarditis, 158 

in umbilical phlebitis, 719 

indican in, test for, 635 
• milky, from urates, 745 



INDEX. 



843 



Urine, nocturnal incontinence of, 748 

a symptom of epilepsy, 291 
of sand in water, 765 
of small-pox, 61 

causation of, 748 

pathology of, 749 

treatment of, 750 
Urine, offensive, from catarrh of bladder, 

746 
Urine, retention of, causes of, 748 

from thread-worms, 748 

in dysentery, 649 

in enteric fever, 78 

in peritonitis, acute, 687 

in tubercular meningitis, 359 

in tumour of medulla oblongata, 337 
Urine, scanty secretion of, 744 

in choleraic diarrhoea, 643 
Urine, yellow, from bile pigment, 746 
Urticaria, 785 

diagnosis of, 786 

in cases of purpura, 248 

symptoms of, 785 

treatment of, 786 
Urticaria pigmentosa, 786 
Uvula, destruction of, in tubercular pha- 
ryngitis, 582 

oedematous in quinsy, 585 

Vaccination, 51 

efficient, 53 

in treatment of eczema, 795 

mode of operating in, 53 

protective value of, 52 

sequelae of, 53 

temperature in, 52 
Valvular disease of heart (see Heart, 

Chronic Valvular Disease of), 544 
Varicella (see Chicken-pox), 48 
Variola (see Small-pox), 55 
Varioloid, 61 

diagnosis of, from varicella, 49 
Veins, fulness of superficial, in catarrhal 
pneumonia, 437 

in cirrhosis of liver, 728 
of lung, 477 

in enlarged bronchial glands, 181 

in tubercular peritonitis, 695 
Venous hum from enlarged bronchial 

glands, 182 
Ventilation of bed-rooms, importance of, 

234 
Vermiform appendix, ulceration of , 678 

diagnosis of, 683 

peritonitis from, 682 

prognosis in, 683 

symptoms of, 682 
Vibration, vocal, often absent in children, 

401 
Vision, disorders of, in megrim, 295 

impaired, in cerebral tumour, 382, 388 
Vocal cords, ulceration of, syphilitic, 204 

tubercular, 416 
Voice, alteration of, in anaemia of larvnx, 
409 

in chronic laryngitis, 408 



Voice, alteration of, in foreign body in air- 
tubes, 530 

in infantile syphilis, 210 

in membranous croup, 95 

in scald of glottis, 407 

in stridulous laryngitis, 412 

in suppuration about 1-irnyx, 420 

in tubercular laryngitis, 416 

in warty growths on larynx, 417 
Voice, nasal, in enlargement of tonsils, 587 

in quinsy, 585 

in retro-pharyngeal abscess, 592 

in tubercular pharyngitis, 582 
Vomiting a sign of cardiac failure, 99 

cerebral, 264, 558 

chronic in infants, treatment of, 607 

clinical importance of, 2 

in amyloid liver, 732 

in atrophic cirrhosis of liver, 728 

in capillary bronchitis, 484 

in cerebral tumour, 332 
treatment of, 339 

in choleraic diarrhoea, 643 

in chronic Bright' s disease, 755 

in fibroid induration of lung, 477 

in gastric catarrh, 611 

in idiopathic anasmia, 233 

in infantile atrophy, 607 

in inflammatory diarrhoea, 631 

in intussusception, 672 

in lymphadenoma, 224 

in malignant diphtheria, 97 

in peritonitis, simple acute, 687 

in peri-typhlitis, 679 

in symmetrical gangrene, 168 

in typhlitis, 679 

in tubercular meningitis, 358 

in umbilical phlebitis, 719 

in whoopiDg- cough a cause of danger, 
118 
Vulva, gangrene of, 170 

treatment of, 171 
Vulvitis, aphthous, 776 

diagnosis of, 776 

symptoms of, 776 

treatment of, 777 
Vulvitis, catarrhal, 775 

symptoms of, 775 

treatment of, 776 

Walk, peculiarities of, in cerebellar tu- 
mour, 337 

in pseudo-hypertrophic paralysis, 385 

in spasmodic spinal paralysis, 383 
Walkiog late in chronic hydrocephalus, 3i3 

in idiocy, 392 

in rickets, 143 
Warty growths on vocal cords, case of, 417 
Wasting, general, from deficient nourish- 
ment, 596 
Wasting of muscle in acute infantile spinal 
paratysis, 375 

in chorea, 303 

in haemorrhage into spinal cord, 377 

in pseudo-hypertrophic paralysis, 386 

in rickets, 134 



844 



INDEX. 



Wasting of third cerebral nerve from pres- 
sure, 375 
rapid, in choleraic diarrhoea, 648 
Wetting- the bed a symptom of epilepsy, 291 
of sand in water, 765 
of small-pox, 61 
Wetting the bed (see Urine, Nocturnal In- 
continence of), 748 
White lead paint as an application for ery- 
sipelas, 113 
White wine whey, 608 

in treatment of gastric catarrh in in- 

fants, 608 
in treatment of post-natal atelectasis, 
i 464 

' in treatment of thrush, 575 
'Whoop, occasional absence of, in pertussis, 

117 
Whooping-cough, 109 

absence of whoop in, 117 

antiseptic sprays in treatment of, 126 

atropia in treatment of, 124 

bacillus of, 115 

bronchitis in, 120 

catarrhal pneumonia in, 120 

stage of, 116 
causation of, 114 
collapse of lung in, 119 
complications of, 117 
convulsions in, 119 
diagnosis of, 123 
treatment of, 127 
croton chloral in treatment of, 126 
diagnosis of, 122 



Whooping-cough, diet in, 124 

digestive derangements in, 118 

duration of, 117 

of infection in, 114 

emphysema of lungs in, 120 

epistaxis in, 117 

fungus of, 115 

haemorrhages in, 116 

morbid anatomy of, 114 

mucous disease after, 121 

nature of, 115 

nervous accidents in, 
agitation in, 115 

paroxysms of, 116 

pathology of, 114 

physiognomony of, 7 

prognosis in, 123 

pulmonary lesions in, 

quinine in treatment of, 125 

rupture of tympanic membrane in, 118 

sequelae of, 120 

spasm of larynx in, 118 
treatment of, 127 

spasmodic stage of, 116 

sub-lingual ulceration in, 117 

symptoms of, 115 

treatment of, 124 

vomiting in, a cause of danger, 118 
Worms, intestinal, 705 

causation of, 707 

diagnosis of, 711 

symptoms of, 708 

treatment of, 711 

varieties of, 705 



118 



119 



3477 
2269 






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